I L1BH-A_RY Ox^ CO^^GMSS. t 

~- - - ^ 

^UNITED STATES OF AMlirJCA.f 



■^a^^ 



PRACTICAL TREATISE 



DISEASES OE CHILDREN 



BY 



ALFKED yOGEL, M.D., 

PEOFESSOK or CLINICAL MEDICINE IN THE TTNIVERSITY OF DORPAT, ETTSSIA. 



TRANSLATED AND EDITED BY 

H. KAPHAEL, M. D., 

LATE HOUSE SUEGEOX TO BELLEVtTE HOSPITAL, ATTENDING PHTSICIAN TO THE EASTERN 
DISPENSARY FOR THE DISEASES OS CHILDREN, ETC., ETC. 



FROM THE FOURTH GERMAN EDITION. 





ILLUSTRATED BY SIX LITHOGRAPHIC PLATES. 



# 



^ NEW YORK : 
D. APPLETOK AND COMPANY, 
90, 92 & 94 GRAND STREET. 

1870. 



<!-. 



Oo 



Enteked, according to Act of Congress, in the year 1869, by 

D. APPLETON & CO., 

In tlie Clerk's Office of the District Court of the United States for the 

Southern District of Xew York. 



TO 

t 

A. JACOBI, M. D., 

CLINICAL PEOFESSOR OF THE DISEASES OF CHILDREN IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, NEW YORK, ETC., 

THE FIRST IN THIS COUNTRY TO DELIVER A SYSTEMATIC 

COUESE OF DIDACTIC LECTUEES ON THE DISEASES OF CHILDEEN, 

AND TO DEMONSTRATE THE PJSDIATRICA BY CLINICAL INSTRUCTION, 

THIS TRANSLATION IS RESPECTFULLY DEDICATED 

BY THE 

TEANSLATOE. 



PREFACE TO THE THIRD EDITIOJST. 



Aftee three years I experience the great pleasure of placing 
my treatise on the Diseases of Children, for the third time, be- 
fore my colleagues and those younger in the profession, and am 
quite convinced that my labor has not been wholly unappre- 
ciated. As a mark of still further recognition, it may be stated 
that two years ago a Russian translation, under the direction of 
M. Zelensky, followed the one in Dutch. As regards the im- 
provements and additions, they are not considerable. But the 
chapter on Diphtheria had to be remodeled, because the descrip- 
tion in the first and second editions answered more to the spo- 
radic form resulting from scarlatina, etc., while the epidemic 
type with which I only became acquainted in the last few years, 
through personal observation, had not been exhaustively esti- 
mated. And now with pleasure I once more present this worlv 
to the young practitioner, trusting that it will aid him on the 
occasions of diagnostic doubt and therapeutic embarrassments, 
to which every beginner is liable, and elevate the vacillating 

confidence in his medical skill. 

ALFEED YOGEL. 
DoEPAT, October, 1860. 



PEEFACE TO THE AMEEICAISr EDITION. 



TowAUD tlie close of 1868 I informed Professor Yogel tliat 
I had taken the liberty of tra,nslating his excellent treatise on 
the Diseases of Children ; he kindly and promptly replied, giy- 
ing his consent to the publication of the translation, informing 
me at the same time that the work was also in the course of 
translation into the Polish language, and that the fourth edition 
of the original was just then in press and would be issued early 
in the year 1869. He yery considerately forwarded to me the 
additional articles of the last edition, and recommended their 
insertion in my translation, in order to make it correspond in all 
respects to the fourth German edition. 

The subjects alluded to are : (1), on the method of preparing 
the so-called Liebig's soup ; (2), on sclerosis of the sterno-cleido 
mastoideus muscle ; and (3), on rubeola — this last the author, in 
common with many eminent European physicians, regards as a 
separate and distinct disease from morbilli. 

The facts of Yogel's " Kinderkrankheiten " haying been 
translated into three other languages, and of its haying attained 
to the fourth edition in less than eight years, together with the 
flattering commendations of the critics in yarious coimtries, and 
his belief in its utility and merit and its adaptation to the wants 
both of the practitioner and the student, must accoimt for the 
translator having undertaken to render an English yersion of it.. 



viii PEEFACE TO THE AMERICAN EDITION. 

Tlie work will be found to be well np to tlie present state 
of pathological knowledge ; complete witlioiit unnecessary pro- 
lixity ; its symptomatology accui^ate, evidently the result of care- 
ful observation of a competent and experienced clinical prac- 
titioner. The diagnosis and differential relations of diseases to 
each other are accurately described, and the therapentics ju- 
dicious and discriminating. All polypharmacy is discarded, 
and only the remedies which appeared useful to the author com- 
mended. 

Without in any way detracting from the merit of the nu- 
merous works upon the Diseases of Children which exist in our 
own and other languages, he ventures to assert* his belief that 
the work of Yogel contains much that must gain for it the 
merited praise of all impartial judges, and prove it to be an 
invaluable text-book for the student and practitioner, and a safe 
and useful guide in the difficult but all-important department 
of Paediatrica. 

In the efforts at converting the original into our own ver- 
nacular tongue, all thoughts of elegancy as to style have been 
renounced ; the only object aimed at was to present it in as clear 
and intelligible language as possible, to make the translation a 
worthy counterpart of the original, and to express the true ideas 
and intentions of the illustrious author ; how well I have suc- 
ceeded, time and the favor which it receives at the hands of the 
profession of this country will tell. 

H. EAPHAEL. 

New Yoek, August^ 1869. 



CONTEJSTTS. 



PAGE 

Preface v 

1.—IXTB0DJ7CT0RT REMARKS. 
CHAPTER I. 

AXATOilO-PATHOLOGICAL OBSERVATIONS UPON 
THE INFANTILE ORGANISM. 

A. — Eespiratioii and Circulation. 

Ductus Yenosus Arantil 1 

Ductus Arteriosus Botalli 2 

Foramen Ovale 2 

Arterise Umbilieales 2 

Thymus Gland , 3 

B. — Secretions. 

Meconium 4 

Uric-Acid Infarction 5 

Cutaneous Secretion, Seborrhoea Ca- 
pillitii 6 

0. — Growth. 

General Growth ^ 

Fontanels , 8 

Eruption of the Teeth 11 

CHAPTER II. 

GENTIRAL RULES FOR THE EXAMINATION OF 
CHILDREN. 

Pulse 11 

Thoracic Cavity 19 

Abdominal Cavity 21 

Cry and Cough 26 

CHAPTER III. 

NURSING AND CARE OF CHILDREN. 

Selection of a Wet-nurse 30 

Analysis of the Milk 32 

Weaning 41 

Artificial Nutrition 43 

Bathing, Dressing, Residence 48 



II.— SPECIAL SUBJECTS. 
CHAPTER I. 

DISEASES ORIGINATING DIRECTLY AS A RE- 
SULT OF THE DELIVERY. 

A. Asphyxia Neonatorum 51 

B. Atelectasis Pulmonum 54 



PAGE 

C. Cephalaematoma 56 

D. Diseases of the Navel 58 

(1.) Inflammation of the Umbilical 

"Vessels 59 

(2.) Blenorrhosa and Ulceration of 

Navel 60 

• (3.) Gangrene of the Navel 60 

(4.) Ulceration of the Umbilical 

Stump..... 61 

(5.) Haemorrhage of the Navel 61 

(6.) Hernige of the Navel 62 

E. Trismus and Tetanus of the New- 

born , , 64 

F. Scleroma 67 

G. Melsena Neonatorum 70 

H. Icterus Neonatorum 72 

I. Conjunctivitis Blenorrhoica Neo- 
natorum 73 



CHAPTER II. 

DISEASES OF THE APPARATUS OP DIGESTION. 

A. — Mouth. 

(1.) Harelip and Cleft Palate 80 

(2.) Constriction of the Mouth 83 

(3.) Imperfect Development of the 

Tongue 83 

(4.) Hypertrophy and Pi'olapse of 

the Tongue . . .-. 84 

(5.) Abnormal Adhesions of the 

Tongue 84 

(6.) Ranula 85 

(7.) Catarrhal Inflammation of the 

Mucous Membrane of the 

Mouth 87 

(8.) Diphtheritis of the Mouth 89 

(9.) Putrid Sore Mouth 93 

(10.) Scorbutic Inflammation of the 

Mucous Membrane of the 

Mouth 96 

(11.) Noma 97 

(12.) Thrush , 99 

APPENDIX. 

{a.) Signification of a Coated 

Tongue in Children 105 

{h.) Difficult Dentition 106 



CONTENTS. 



PAGE 

B. — Parotis. 

(1.) Inflammation of the Parotid 

Gland Ill 

(2.) Hypertrophy of the Parotid 

Gland 116 

0. — Pharynx and (Esophagus. 

(1.) Angina Tonsillaris IIY 

(2.) Hypertrophia Tonsillarum 119 

(3.) Retropharyngeal Abscesses... 120 
(4.) Inflammation of the (Esopha- 
gus 122 

(5.) Congenital Fistula of the Neck. 123 
(6.) Sclerosis of the Sterno-cleido- 

mastoideus Muscle 124 

D. — Stomach and Intestinal Canal. 
(1.) The Most Important Symptoms 
of Diseases of the Stomach 

and Intestines. 124 

(a.) Dyspepsia 125 

(6.) Bulimia 127 

(c.) Vomiting 128 

{d.) Flatulence and Colic 131 

(e.") Diarrhoea , . . ' 135 

(/.) Constipation 138 

(2.) Catarrh of the Gastric Mucous 

Membrane 140 

(3.) Toxic Inflammation of the 

Stomach 141 

(4.) The Perforating Ulcer of*the 

Stomach 144 

(5.) Hsemorrhagic Erosions of the 

Gastric Mucous Membrane. . . 144 
(6.) Catarrhal Inflammation of the 

Intestines 150 

(Y.) Enteritis Folliculosa and Tabes 

Mesenterica 156 

(8.) Dysentery— The Flux 160 

(9.) Intussusceptions 163 

(10.) Ingumal Hernia 166 

(11.) Fissura Ani 168 

(12.) Polypi of the Rectum 169 

(13.) Prolapsus Ani lYO 

(14.) Malformations of the Anus and 

Rectum 172 

(15.) Contagious Diseases with Pre- 
ponderating Localization upon 

the Intestinal Canal 1*75 

(a.) Typhus AbdominaUs 1*75 

(6.) Cholera Asiatica 195 

(16.) Entozose, Enthelminthes, Hel- 
minthiasis, Worm Disease. . . . 201 

E. — Liver. 
(1.) S}T)hilitic Inflammation of the 

Liver 210 

(2.) The Fatty Liver 211 

(3.) Congenital Anomalies 214 

F. — Spleen. 
Intermittent Fever 216 



PAGE 

G. — Peritonceum. 

(1.) Peritonitis 219 

(2.) Ascites 222 

(3.) Diseases of the Mesenteric 

Glands 224 



CHAPTER III. 

DISEASES OF THE ORGANS OF CIRCULATION. 

A. — Heart and Vascular Trunlcs. 

(1.) Congenital Anomalies 224 

(2.) Endocarditis, Pericarditis, and 

Rheumatismus Acutus 231 

(3.) Hydropericardium 240 

B. — Arteries and Veins. 

(1.) Erectile Tumors 242 

(2.) Thrombi of the Sinuses of the 

Dura Mater 244 



CHAPTER lY. 

DISEASES OF THE ORGANS OF RESPIRATION. 

A. — Rasal Canities. 

(1.) Epistaxis, Bleeding of the Nose, 245 

(2.) Coryza, Rhinitis, Catarrh 24Y 

(3.) Adventitious Growths in the 

Nose 248 

(4.) Foreign Bodies in the Nose. . . 250 

B. — Larynx and Trachea. 

(1.) Croup 251 

(2.) Pseudo-croup 258 

(3.) Neuroses of the Larynx 270 

(a.) Spasmus Glottidis 270 

ih.) Paralysis Glottidis 278 

C— Thyroid Gland. 
Struma 279 

D. — Thymus Gland. 

E. — Lungs. 

(1.) Bronchial Catarrh 282 

(2.) Pneumonia 289 

(3.) Acquired Atelectasis of the 

Lungs 298 

(4.) Pulmonary Emphysema 801 

(5.) (Edema Pulmonum 303 

(6.) Hsemorrhage from the Lungs . . 305 
(7.) Heemoptoic Pulmonary Infarc- 
tion 306 

(8.) Gangrene of the Lungs 307 

(9.) Tuberculosis of the Lungs and 

Bronchial Glands 309 

(10.) Carcinoma of the Lungs and of 

the Mediastinum Anticum. . . 316 

(11.) Whooping-cough 318 

(12.) Periodic Night-cough 330 



CONTENTS. 



XI 



'F.— Pleura. 



(1.) Pleurisy 

(2.) Hydrothorax. 



331 
337 



CHAPTER Y. 

DISEASES OF THE NERVOUS SYSTEM. 

A. — Brain. 
(1.) Hydrocephalus Acutus Inter- 

nus 339 

(2.) Meningitis Simplex, Purulenta, 

and Encephalitis 359 

(3.) Sunstroke 362 

(4.) Hvdrocephaloid and Irritatio 

Cerebri 363 

(5.) Hydrocephalus Chronicus 365 

(6.) Encephalocele 370 

(7.) Sclerosis of the Brain 372 

(8.) Neoplasms of the Brain 372 

(a.) Tubercle 373 

(6.) Carcinoma 374 

{c.) Entozose 374 

(9.) Congenital Malformations 375 

B. — Diseases of fhe Spinal &ord and 
Memlranes. 

(1.) Spinal Meningitis and Myelitis.. 376 
(2.) Spina Bifida, Hydrorrhachia . ... 380 

C. — Disturbances of the N'erdous 
Functions. 

(1.) Eclampsia Infantum — Convul- 
sions 383 

(2.) Paralysis 390 

(3.) Chorea Minor 395 

(4.) Chorea Major 404 

(5.) Epilepsy 407 

APPENDIX. 

Diseases of the Mind 417 

D. — Eiglier Organs of Sense. 

I.— Sight 420 

(1.) Epicanthus 420 

(2.) Cyclopia 421 

(3.) Malformations of the Eyeball... 421 

II.— Hearing 423 

(1.) Malformation of the Organ of 

Hearing 423 

(a.) Absence of the Auriculse 423 

(6.) Occlusion of the Meatus Audi- 

torius 424 

(2.) Simple Inflammation of the 

Meatus Auditorius 425 

(3.) Abscesses in the Meatus Audi- 
torius 428 

(4.) Inflammation of the Middle 

Ear 429 

(5.) Foreign Bodies in the Ear 435 



PAGE 

CHAPTER VI. 

DISEASES OF THE BLADDER AND GENITAL 
ORGANS. 

A. — Kidneys. 

(1.) Malformation of the Kidneys. . . 437 
(2.) Uric- Acid Infarction of the 

New-born 437 

(3.) Morbus Brightii 439 

(4.) Renal Calculi, Renal Tubercles, 

Renal Cysts 444 

B. — Bladder. 

(1.) Malformation 445 

(2.) Cystitis 448 

(3.) Incontinentia IJrinse 450 

(4.) Ischuria 452 

(5.) Vesical Calculi 453 

C. — Male Genitals. 

I. — Penisi 456 

(1.) Malformations 456 

(2.) Balanitis 458 

(3.) Acquired Paraphimosis 459 

(4.) Onanism 460 

II.— Testis 462 

(1.) Cryptorchidia 462 

(2.) Hydrocele 463 

D. — Female Genitals. 

(1.) Malformations 466 

(2.) Catarrh of the Genital Mucous 

Membrane 468 

(3.) Diphtheritis and Gangrene of 

Female Genitals 470 

(4.) Vaginal Haemorrhage 471 

(5.) Inflammation of the Breasts 472 

CHAPTER VII. 

DISEASES OF THE SKIN, 

(1.) Scarlet Fever 474 

(2.) Measles 484 

(3.) Rubeolce 494 

(4.) Variola— Small-pox 496 

Vaccination 499 

(5.) M.odified Small-pox, Varioloid 

and Varicella, Chicken-pox. . . 505 

(6.) Erythema Neonatorum 509 

(7.) Erysipelas 510 

(8.) Intertrigo (Chafing) 511 

(9.) Furunculosis 512 

(10.) Scabies— Itch 513 

(11.) Mothers' Marks (Congenital 

NfBvi) 516 

(12.) Burns (Combustio) 517 

(13.) Congelatio, Frost-bite, Chil- 
blain 518 



Xll 



CONTENTS. 



CHAPTER YIII. 

GENERAL DISEASES OP THE SECRETIONS. 

Byscrasice, Cacliexm. 
(1.) EacMtis, Rickets, English Dis- 
ease, Double Limbs 520 

A. Rachitis of the Skull 525 

B. Rachitis of the Thorax 527 

C. Rachitis of the Pelvis and of 

the Extremities 529 

(2.) Tuberculosis and Scrofulosis. . . 534 
A. The Tuberculous Cachexia. . 535 



PAGE 

B. The Scrofulous Cachexia 540 

(a.) Skin 542 

(6.) Mucous Membrane and Organs 

of Sense 546 

Nose 546- 

Eye 547 

Ear 551 

(c-.) Lymphatic Glands and Subcu- 
taneous Cellular Tissue 551 

(d) Bones 553 

(V) Joints 568 

(3.) Hereditary Syphilis 586 



EXPLAKATIOlSr TO PLATES. 



PLATB I. 



I. Placenta. II. Liver. III. Heart. IV. Kidneys. V. Bladder. 
(1.) Arcli of the Aorta and vessels of the neck arising from it. 
(2.) Ductus arteriosus Botalli. 
(3.) x4.rteria pulmonalis. 
(4.) Ductus venosus Arantii. 
(5.) Vena cava superior. 
(6.) Vena cava adscendens. 
(7.) Venae pulmonales. 
(8.) Vena umbilicalis. 
(9.) Arteri^e umbihcales. 

PLATE II. 

Figs. 1 and 2. Schematic drawings of the Parietal Bone for the demonstration of the 

physiological enlargement of the greater fontanel. 
Fig. 3. Normal human Milk, according to Funke. 
Fig. 4. Normal Colostrum, according to Funke. 
Figs. 5, 6, and 7. Schematic Sections of various kinds of Cephalsematomse. Fig. 5. 

Cephalffimatoma subpericranicum. Fig. 6. Ceph. subaponeuroticum. Fig. 7. Ceph. 

duroe matris. 

(1.) Scalp. (2.) Galea aponeurotica. (3.) Pericranium. (4.) Cranial bone. 
(5.) Dura mater. (6.) Bony-ring (only possible in Fig. 6). 
Fig. 8. Schematic Section of an Umbilical Stump, (a) Stump, {h) the Cutaneous Eing 

surrounding it. 
Fig. 9. a and I Schematic Delineation of the so-called Flesh-navel, (a), previous; 

(5), after the Cord has fallen off. 

PLAT3EI HI. 

Fig. 1. Impressions of the Teeth in the Tongue in Stomacace. 

Fig. 2. Thrush-fungi, according to Kuechenmeister. 

(a) Fragment of a detached Thrush-membrane, {h) and (c) Spores, {cT) Thallus 
filaments with sheaths, {e) Free end of a Thallus filament slightly thickened, {g) 
Thallus filaments, with indentations. 

Fig. 3. A^ Intussusception of a piece of the Intestines ; JB^ Schematic Section, accord- 
ing to Foerster. (a) the Intussusceptum, (I) the Eeflccted portion, and (c) the 
Sheath, {d) and {e) the place of reflection, (/) the dragged in Mesentery. 

Fig. 4. Longitudinal Section of the Sacrum and of the Eectum. (1.) Sacrum. (2.) Eoc- 
tum. (a) upper, (i) middle, and (e) lower portion of the Eectum. (3.) Peritoufeum. 
(4.) Uterus. (5.) Vagina. (6.) liabia. (7.) Bladder. (8.) Periua^um. 



Figs. IL 


|12, 


Fig. 


11. 


u 


12. 


u 


13. 


u 


U. 



xiv EXPLANATION TO PLATES. 

Figs. 5, 6, Y, 8, and 9. Scliematic sections of imp erf oration of tlie Eectum and of its 
abnormal terminations : (r), Eectum ; («), Nates-fold ; (a), Anal-inv agination ; (J), 
Bladder; (^), Vagina. 
Fig. 10. Schematic delineation of an Ectopia of tlie Bladder, according to Foerster. 
13, and 14. Schematic representation of Hydroceles. 
Hydrocele canalis vaginalis testiculi aperta. 
Hydrocele fundi canalis vaginalis testiculi dausa. 
Hydrocele colli canalis vaginalis testiculi aperta. 
Hydrocele colli canalis vaginalis testiculi dausa. 
(a), Piece of the Peritonceum viewed from within ; (5), Open canalis va- 
ginalis ; (c). Testicle ; (d), Dropsical distension of a portion of the 
Inguinal Canal. 



PLATE IV. 

Figs. 1-3. Bothriocephalus latus. 

Fig. 1. Head, natural size. 

Fig. 2. Magnified head with long neck. 

Fig. 3. Single pieces. The sexual opening is seen in the centre of each joint. 
Figs. 4-7. Tffinia solium. 

Fig. 4. Head, natural size. 

Figs. 5 and 6. Magnified Head, seen from the side and from above. 

Fig. 7. Joints. The sexual opening is seen at the side. 
Figs. 8-9. Ascaris lumbricoides, Eound-worm. 

Fig. 8. A ruptured female of natural size, with prolapsed intestines. The brown- 
ish-colored pouch is the alimentary canal, the white coils are the ovaries. 

Fig. 9. 'The curved tail of the male with double prongs, magnified. 
Figs. 10-13. Oxyuris vermicularis, Thread-worm. 

l^igs. 10 and 11. Female, natural size and magnified. 

Figs. 12 and 13. Male, magnified and of natural size. 
Figs. 14 and 15. Tricocephalus dispar, "Whip-worm, natural size. 

Fig. 14. Female. Fig. 15. Male. 

PLATE V. 

Figs. 1 and 2. Schematic section of (1) normal, and (2) rachitic infantile thorax. 

(1.) Sternum. (2.) Costal Cartilages. (3.) Eibs. (4.) Eibs divided by the sec- 
tion. (5.) Intercostal spaces. (6.) Fifth dorsal vertabra. (7.) Heart. (8.) 
Bulbous, rachitic hypertrophy. 



PLATE VL 

Fig. 1. Eachitic costal ends, according to Virchow. 

Fig. 2. Sections of the same. 

Fig. 3. Section of a rachitic femur. 

Figs. 1^ 2, 3. (a), bluish layer of large cancellous bony extuberance ; (5), Goblet-shaped 
tumefaction of the young bones ; (c), Dentated wave-line between the cartilage 
and bone. 

Fig. 4. Eachitic Skull. Craniotabes, according to Elsaesser. On the light-colored 
places the calcareous salts have disappeared, dura mater and pericranium are in con- 
tact with each other. 



PART I. 

IJS^TE OD UCTOB Y BE3IABKS. 



CHAPTER I. 

ANATOMO-PATHOLOGICAL EEMARKS UPON THE INFANTILE 
ORGANISM. 

A. Respieation an^d Cieculatioj^. — The first act of the new-born 
is to inspire. Immediately after birth the muscles of inspiration 
contract, and the air finds its way for the first time into the pulmonary 
vesicles. The increase in volume of the lungs consequent upon this 
act gives rise on the one hand to an outward enlargement of the 
thorax, but on the other to a compression of those internal organs of 
the chest in juxtaposition with the lungs, i. e., heart, large blood-vessels, 
and thymus gland, and also to a depression of the diaphragm, whereby 
a palpable pressure is necessarily exerted upon the abdominal viscera. 
This sudden change in volume of both thoracic and abdominal viscera, 
in connection with other physiological alterations, leads doubtless to 
alterations in the circulation of the different organs, and the following 
foetal circulation, in fact, becomes established immediately or soon after 
birth. 

(1.) The Ductus Yenosus Arantii (Plate I., Fig. 2). — The umbiHcal 
vein arising from the placenta (PI. I., Fig. 5), after its entrance 
through the umbilical ring, runs between the peritonaeum and transver- 
salis muscle to the liver, and through the fossa longitudinalis anterior 
sinistra backward to the left end of the fossa transversa. Here it 
divides into two branches, of which one, the larger, communicates 
with the portal vein, and the smaller, the ductus venosus Arantii, 
leads into the inf. vena cava (PI. I., Fig. 3). The duct. ven. Aran- 
tii, therefore, connects the vena cava ascendens with the umbilical 
vein, but this connection, as well as that with the portal vein, ceases 
as soon as the placenta is expelled from the uterus, and the blood in the 
1 



2 DISEASES OF CHILDREX. 

umbilical Tein lias become stagnant, and the first inspiration taken 
place. 

(2.) The Ductus Arteriosus JBotaUi (PL I., Fig. 2) is, in tbe foetus, 
a communicating canal between tbe pulmonary artery and the aorta. 
It arises at the point where the jDulmonary artery divides into the two 
branches, then runs obhc^uely upward toward the lower border of the 
arch of the aorta, and joins the latter at a point opposite to where the 
left subclavian artery dips into it from above. It serves to arrest the 
blood in its course toward the lungs, and to conduct it from the 
right side of the heart directly into the great current again. The 
nearer the end of gestation arrives the smaller this vessel becomes, 
while the two branches of the pulmonary artery grow larger; the 
broader, however, this vessel is, so much the narrower is that portion of 
the aorta which hes between it and the heart. And now the lungs, 
dilated by the inspiratory muscles, not only draw in air, but also blood 
from the vessels ; not only the air-vessels^ but also the Uood-con&actmg 
system of vessels, become distended. A stronger and faster blood- 
current passes from the pulmonary artery toward the lungs ; the artery 
sends no more blood through the foetal passage communicating with 
the aorta {the ductus Sotalii)^ and the latter is so c[uicMy obliterated, 
that in a child twenty-four to thirty-six hours old it is scarcely large 
enough to admit a probe. 

(3.) The Foramen Ovale. — In the foetus the auricular septum con- 
tains an opening (for. ovale), corresponding to the fossa ovalis in the 
adult. In this opening a semilunar membranous valve (valvula fora- 
minis ovalis) is found, the upper border of wliich is free. In the 
foetus this valve closes the foramen very imperfectly, so that a por- 
tion of the blood passes directly from the right into the left auricle, 
and thence, without permeating the lungs, into the general circulation. 
The nearer the end of gestation arrives, therefore, the smaller this fora- 
men becomes, and the stronger and firmer the valve. After birth, the 
lungs are suddenly converted into a suction-a^Dparatus, they therefore 
require a larger quantity of blood for their supply ; the right ventricle 
also becomes distended, and thus the blood-stream is diverted from the 
foramen ovale. Although the border of the valve usually remains free 
for some months, still it is so well developed that it accm-ately closes 
the foramen. In children over eight to ten months of age, this border 
of the valve is generally found united with the corresponding border 
of the foramen ovale. 

(4.) The UmMlical Arteries (art. umbihcales, PI. I., Fig. 4). — Hav- 
ing spoken of the umbihcal vein in connection with the closure of the 
duct. ven. Arantii, there only remains to describe the obliteration 
of the umbilical arteries. The two arteries originate from the cor- 



REMARKS UPOX THE INFANTILE ORGANISM. 3 

responding arter. li^^ogastrica, are thicker than all its other branches, 
and pass upward along the bladder. They embrace the urachus and 
with it run upward between the abdominal muscles and peritongeum 
to the umbilicus. Passing through the umbilical ring, they run spirally 
in the cord, and reach the placenta, in which they divide and subdivide. 
As soon as the connection between the uterus and placenta has ceased, 
thrombi form in the umbilical arteries, reaching almost to their origin 
from the hypogastrica. These arteries remain pervious for a short 
distance fi^om their point of origin, and here give off several arter. 
vesicales ; in the female, in addition the arter. uterinse. The remain- 
ing portion, between the arter. vesic. and the ring, ultimately becomes 
obliterated and converted into a fine white cord. 

Together ^vith these 'mechanical alterations, still more important 
chemical processes take place from the entrance of air into the 
luno;s. Throuo;h the alternate action of air and blood, and the inter- 
change of gases, which the walls of the capillaries lying against the 
pulmonary alveoli and the walls of the alveoli themselves have 
to transmit in two opposite directions, both air and blood are so 
altered, that the former becomes irrespirable, the latter arterial and 
thus qualified for nutrition. The new-born has now both arterial 
and venous blood. 

Mention must be made here of an organ that solely belongs to 
the infantile organism, the thymus gland. The thymus is distinguished 
for great variation in size, weight, consistency, and form. 

Embedded in the anterior mediastinum, it is sometimes confined to 
the space between the upper part of the pericardium and the roots of 
the large vessels, measuring in width barely half an inch, but some- 
times reaching fi:om the thyroid gland down to the diaphragm, and 
then measuring more than two and a half inches in width. Its principal 
arteries, according to Jendrassic^ are branches derived directly from 
the large blood-vessels upon which it lies. According to the same 
author, to whom we are indebted for most of our knowledge concerning 
this enigmatical organ, the thymus is composed of two, often very 
unequal, parts, which are united by a membrane formed of several 
delicate laminae, in w^hich most of the principal vessels terminate. 
The form of such a thymus moiety most frequently met with is an 
oblong, the upper third sometimes thin and rounded, while the rest 
is more flattened and broader; a larger or smaller portion often 
curves upward like a horn from the lower end over the outer border 
of the gland. When the thymus deviates from this form, each half 
has the shape of thin cord4ike stripes, or when of large size is di\"ided 
into several rounded lobules, intimately imited by a thin parenchyma- 
tous structure, lying near or upon each other. 



4 DISEASES OF CHILDREN. 

In all instances the anterior surface facing the sternum is convex, 
the posterior slightly concave. The outer and lower borders are thm, 
often hem-like ; the inner is blunter, provided mth deep fissures, in 
which, as in a hilum, the blood-vessels dip. 

At first the thymus is solid, firm, and granular, but in time be- 
comes converted into a softer mass, in which many cavities may be 
found containing a fluid that almost always reacts with acid. The 
softening progresses from the central axis, where the principal veins 
terminate in an extensive deposit of connective tissue toward the 
periphery. The gland grows constantly flatter, its cavities approach 
one another more closely, so that no more of a glandular parenchyma 
can be seen, and at the time of commencing puberty it has, as a rule, 
completely disappeared. Exceptionally, however, it may be found in 
adults, and sometimes even of decided dimension and weight. In 
tuberculous children it is found infiltrated with tubercular deposit. 
Carcinoma of the anterior mediastinum, which in children occurs com- 
paratively more frequently than in adults, most probably has its start- 
ing-point in the thymus gland. The numerously-repeated statements, 
that in syphilitic children abscesses are to be found in the thymus, are, 
according to Jendrassic, based upon an erroneous supposition, for, in 
most instances, the supposed abscesses are nothing more than the 
cavities that are regularly developed in the retrograde metamorphosis 
of the gland, and are also found in children who are perfectly free 
from syphilis. 

JB. Seceetioxs. — All the mucous membranes, which in the foetal 
state produced but a slight amount of secretion, commence after birth 
to secrete their peculiar fluids. The mouth and nasal cavities be- 
come moist and lubricated, the latter often very imperfectly, so that it 
frequently becomes necessary to remove the dried mucous crusts. The 
salivary glands, it is true, also secrete a fluid, which, however, has not, as 
yet, the same perfect chemical properties as in the adult, for it is only 
able to very slowly convert starch into sugar. The stomach likewise 
begins to secrete a fluid, which dissolves the caseine contained in the 
milk of the mother. The liver, which fills up the greater part of the 
abdominal cavity, secretes a hght-brown bile, which gives to the faeces, 
after the dark-brown meconium has been evacuated, an orange-yellow 
color. 

The generally prevailing oi^inion, that the meconium is a mixture of 
bile, intestinal mucus, and intestinal epithelium, has been proven by 
Foerster''s investigations to be incorrect. It consists rather of flat 
scales, which jDOSsess all the characteristics of flat epithelium, and 
consequently could not have originated in the intestinal canal, re- 
sembling in their entity those of the vernix caseosa : and, in addition. 



REMARKS UPOX THE IXFAXTILE ORGAXISM. 5 

of fine hairs, in tlie same quantity as in the latter, fat-globules of vari- 
ous sizes — e^-identlj cutaneous fat (Hauttalg, smegma cutaneum) 
peculiar to the vernix caseosa — crystals of cholesterine (which may 
partly originate in the bile, or may be retrograde products of the ver- 
nix caseosa), and irregular brownish and yellowish lumps and flakes, 
which give to the meconium its dark color, and without doubt 
the coloring matter of the bile. It is therefore evident, that the 
meconium, excepting the last-mentioned substances, which origi- 
nate in the bile, consists principally of vernix caseosa; and from 
this it may be inferred that the foetus from time to time has swal- 
lowed a tolerably large quantity of amnion containing the vernix 
caseosa in suspension, the water of which is quickly absorbed by 
the stomach, for none is ever found in it, but the hairs and 
scales pass through the whole intestinal tract as indigestible sub- 
stances. 

After birth the intestines secrete a certain amount of mucus, an 
excessiveness or deficiency of which will give rise to diarrhoea or 
constipation, the first and most frequent diseases to which the nurs- 
ling is subject. 

Quite a severe task is imposed upon the kidneys immediately 
after birth. In the first few days children drink but very little, the 
blood consequently can part with only a very small quantity of water, 
and thus it happens that the uric acid salts, the result of the great 
metamorphosis of the tissues, quickly accumulate in the urinary tu- 
bules, remain undissolved there, and from this too highly concentrated 
solution the product that has been called the uric acid infarction of 
the new-born is deposited. The uric acid concretions are yellowish- 
red or pink-red casts of the pyramids near the papilla. Generally 
they appear for the first time on the second day after birth, and last 
from five to twelve days, but I have also found them in children more 
than four weeks old. As this condition has been said to exist in the 
still-born, in very exceptional cases it is true, and, since a considera- 
ble number of children who die between the second and fourteenth 
days do not exhibit it, no very great medico-legal value can therefore 
be placed upon it. It is frequently found as a carmine red powder in 
the diapers of the new-born, an occurrence that has also been noticed 
by some observing midwives. Microscopic examination reveals mi- 
nute columns composed of cylindrical, amorphous, urate of ammonia, 
and epithelium cells, with here and there solitary rhomboid uric acid 
crystals. On the days this powder is found in the diapers, the chil- 
dren are usually restless, cry on micturition, and have an inflamed 
meatus. Although its origin and excretion must be regarded as 
physiological, nevertheless it cannot be denied that kidney gravel, so 



6 DISEASES or CHILDREN. 

frequent in children, as well as the occurrence of urinary calculi in 
childhood, has some connection with it. 

The skin, which during foetal life was continuously of the tem- 
perature of the maternal blood, with the act of delivery becomes a 
colder medium, for now it is subject to the impressions of the air, 
light, and changes of temperature, and also assumes the function 
of secretion. At birth it has a uniform red color, which, however, 
between the second and sixth day, changes to a yellowish and then 
into the ordinary rosy-red tint. The yellowish color is often errone- 
ously regarded as icteric. New-born children are covered almost all 
over the body, with the exception of the palms of the hands and soles 
of the feet, with fine, soft, often tolerably long hairs (lanugo), which 
fall out in the first weeks of life. So, too, the strong hairs upon the 
head with which children sometimes come into the world, fall out 
in the first weeks of life, and are only slowly replaced by a fine, gen- 
erally light-colored growth of hair. Feeble children, of slow de- 
velopment, and those devoid of solid adipose tissue, retain these 
first hairs much longer than those which develop rapidly. In the first 
weeks of life the sweat-glands perform their function but very imper- 
fectly ; it is almost impossible to bring a child, under four weeks 
old, into such a state of transpiration that the perspiration will gather 
in drops. 

On the other hand, from the beginning of the second month up 
to the end of the first year, the secretion of the sebaceous glands of 
the scalp in almost all children is increased in amount, forming sebor- 
rhoea capillitii, which should be classed with the physiological 
conditions. This seborrhoea capillitii develops very gradually; at 
first, the scalp looks as if it had been smeared with tallow or cerate ; 
upon this hard skin dust and dirt become adherent, and, with the 
lardaceous secretion of the skin, dry into grayish-white or yellowish, 
and, subsequently, into brown and even black scabs, which crumble 
easily between the fingers, become detached, and leave the scalp in 
a healthy, uninjured state, and not even congested. It is not attend- 
ed by any itching, moisture, or cutaneous infiltration. By a diligent 
application of olive-oil, and washing the head with soap and water, 
this formation of scabs may be arrested without any danger to 
health. In many places, in Munich for instance, the midwives have 
accused this affection of being a noli me tang ere. It is but seldom 
possible to persuade the mothers to try the just-described method 
of treatment, most of them leaving the broAvn scabs untouched 
till the end of the first year, when the seborrhoea ceases spontane- 
ously, and the scabs, by the constant growth of the hair, are separated 
more and more from the scalp, and finally dry up and crumble 



REMARKS UPOX THE INFANTILE ORGANISM. 7 

away. Afterward, no simple seborrhoea capillitii ever occurs in 
children. 

C. The gexeeal geowth of Childeei^, aotd of special Paets 
OF THEiE Bodies. — The child grows most rapidly in the first weeks of 
life ; in the first year, from six to seven inches. From the fourth 
or fifth year up to the sixteenth, its growth is tolerably regular, and 
amoimts yearly to two inches, more or less. From the sixteenth to 
the seventeenth year, the body increases only one and a half inches ; 
in the two succeeding years only one inch. Most persons grow only 
to the end of the twentieth year, but in some growth is only com- 
pleted at the end of the twenty-fifth year. Imperfect nutrition, and 
too hot and too cold a climate, hinder growth. Acute febrile diseases 
interfere in no way with it ; on the contrary, they accelerate it most 
decidedly, and this is especially true of the acute exanthemata. In 
an acute febrile disease of a few weeks' duration, children often 
grow a half or one inch, while in the physiological state this would take 
three or six months time. Indeed, they even appear to have grown 
more than that amount, on account of the great emaciation that 
ensues. Diseases of the bones, rachitis, and scrofulous afi'ections, 
retard the growth. When children grow too rapidly, they become 
emaciated, weak, pale, and inert. In about one and a half to two 
months the child begins to hold the head erect and to turn it voluntarily, 
especially toward the light. Not till the seventh or eighth month 
does it learn to sit, and still later in the ninth and tenth the func- 
tions of the lower extremities are developed, the child beginning to 
stand, and several weeks thereafter to walk. 

The growth of aU parts of the body does not always progress 
uniformly ; often the head grows more than the other portions, and 
the extremities more than the trunk and head ; most frequently the 
thorax, in consequence of our defective physiological rearing, is 
much retarded in development as to its breadth. 

Sometimes it is of importance to accurately decide the dimensions 
of the bones of the skuU, and the following points of measurement 
have therefore been agreed upon : (1.) The largest periphery of the 
head. For this the measurement is taken from the tuberosity of the 
occipital bone to the greatest prominence of the frontal bone. In 
marked chronic hydrocephalus the occipital bone is more horizontal, 
and the largest periphery, therefore, strikes above the tuberosity of 
the occiput. (2.) The measurement from one ear to the other. It 
runs from the upper part of attachment of the auricula over the greater 
fontanel to a point opposite. (3.) The measurement from the oc- 
ciput to the root of the nose^ is from the occipital protuberance over 
the top of the head to the glabella. These three measures may be 



8 DISEASES OF CHILDREN. 

taken with some strips of paper, or still better, with a tape measure 
divided into half and quarter inches. The diameters must be meas- 
ured with a compass. The transverse diameter has its terminal points 
at the protuberances of the two parietal bones, the longitudinal 
diameter at the lesser fontanel and the greatest protuberance in the 
centre of the forehead. 

A thorough knowledge of the greater fontanel and its physiologi- 
cal closure is of great importance to the physician. The fontanels 
are conditional upon the development of the skull. The angles of 
the bones of the skull will necessarily have to be the last formed, as 
the process of ossification of the foetal skull progresses from several 
points of ossification, which, by the addition of ossific matter to 
their peripheries, grow 'uniformly in every direction. But since the 
cranial bones at first have a roundish contour, there will remain, 
when the several plates of bone come together, a space between them, 
which will have as many margins as bony plates. These openings, 
covered only by a membranous tissue, are called fontanels. Now, 
since the parietal bone in its developed state has four angles, a 
fontanel would have to form at each of these in the embryonic 
state, but as the upper angles of both parietal bones lock together, 
so that their fontanels coalesce, only six fontanels can be produced, 
of which the frontal and occipital are single, but the anterior 
and posterior parietal fontanels, on the contrary, are disposed in 
pairs. 

In a child at full term, only the large four-cornered frontal fontanel 
exists, the square of which forms a rhombus, with unequally in- 
wardly-curved borders. It originates from the union of the two 
frontal and the two parietal bones ; the angle formed by the union of 
the frontal bones being sharper than that formed by the union of the 
two parietal. The greater fontanel seldom closes completely before 
the end of the second year. TJie enlargeinent of this fontanel till after 
the ninth month of life is a very remarkable occurrence, to which 
Elsaesser first called the attention of the profession. To ascertain its 
size, Elsaesser chose a method by which jirobably a more precise and 
at least more relatively definite determination of its square space is 
arrived at, while at the same time it supplies a briefer expression. 
He measured the distance of two parallel sides, lying opposite each 
other, from their centres outward, the distance of the two other parallel 
sides was then similarly ascertained, the two numbers resulting there- 
from were then added together, and the half of that was accepted as the 
diameter of the fontanel. This method furnishes more exact results 
than when the measurement is taken from one corner to the opposite 
one. In the latter case the result is wholly unreliable, because the 



REMARKS UPOJ^ THE INFANTILE ORGANISM. 9 

angles often extend tolerably far into the sutures in the form of very 
narrow fissures, whereby the boundary from which the measures are 
to be taken is always subject to arbitrariness. 

The relative sizes of the anterior fontanel were in the trimesters 
as follows : 







Average Dicameter of the Fon- 


Trimesters. 


No. of Children. 


tanel in French lines. 


1 to 3 months. 


10 


9 60 


4 to 6 " 


15 


11.93 


Tto 9 " 


Y 


13.90. 


10 to 12 " 


13 
45 


11.88 


1 to 12 months, 


11.60 


In this period the fontanel 






is always open. 






13 to 15 months. 


9 


T.n 



Of these nine children the fontanel is closed in 3, in one 5, in the 
rest 10 to 15 lines wide. 

16 to 18 months: eight children. In 4 the fontanel is closed; in 
the rest 2, 3, 9, and 10 lines wide. 

19 to 21 months : five children. In 2 closed ; in the rest, 5, 12, and 
12 lines wide. 

22 to 24 months : seven children. In 5 closed ; in the rest 9 and 
15 lines wide. 

From this it follows — 

1. That the anterior fontanel, during the first year of life, is small- 
est in the new-bom, and in the course of the first trimesters. 

2. That it then increases in size up to the third trimester ; and, 

3. It does not decrease again till the fourth. 

The question which instantly strikes one here, " How is this en- 
largement of the circumference of the greater fontanel to be ex- 
plained ? " may be answered, according to Elsaesser^ in the following 
mechanical way: The greater fontanel forms a square, with its 
angles directed forward and backward, right and left. Through the 
angles two bony fissures of the skull run, a transverse (the coronal 
suture) and a longitudinal one (sagittal and frontal). Now, if we 
suppose that the surface-growth of the bones of the skull occurs in this 
wise, that on their borders new layers of bony substance are constantly 
formed, the relative bones will be driven asunder by the newly-formed 
epiphysis on the borders of each suture. Now, if this happens to 
the fissures terminating at the fontanels, then they will necessarily 
grow larger in every direction, if their borders do not also grow at the 
same time. The borders, however, of the fontanels do indeed grow, 
but only in the same proportion as the margins of the sutures, and this 



10 DISEASES OF CHILDEEN. 

suffices to explain the mecliaiiical enlargement of the fontanel. If we 
think but a little further, that if only one of the above-named principal 
sutures — the transverse for example — receives new additions of mat- 
ter, the other, the longitudinal, remains unaltered, supposing, still 
further, that on each border of the transverse suture material is added 
in a certain period of time, amounting to the breadth of one French 
line, then the fontanel at the expiration of this period will in this case 
have its old diameter again, although the borders have gro^\Ti by one 
line within that same period of time. Thus, then, a uniform growth 
of all the borders of the bones has been presupposed, the diameter of 
the fontanel remaining unaltered, if only one suture passed through it, 
or if no addition of substance whatever took place. But the latter oc- 
curs in the longitudinal suture in the same proportion as in the transverse. 
And since, in the growth of the borders of the transverse suture by 
one line, the borders of the fontanel must also grow by one line if 
its diameter should remain the same, then the same results in the 
longitudinal suture, if, uniformly with the transverse suture, it grows 
by one line in breadth ; or, in other words, if the diameter of the 
fontanel is to remain unaltered during the time in which the borders 
of the transverse and longitudinal sutures grov/ by one line, it must 
increase by double the quantity^ namely, by two hnes. This, how- 
ever, does not take place, the fontanel growing in about the same 
proportion as the margins of the sutures (thus, in the presumed 
period of time merely by one, not by two lines), and it must, there- 
fore, constantly increase in circumference. This is also actually the 
case. To whom the preceding explanation should not be distinct 
enough, let him take the trouble to cut out from paper four times the 
two contours, PI. 11., Figs. 1 and 2, and then to set them together 
with the blunt angles in such a mamier that the fine Hnes a and a' 
of each figure will form a square. 

Fig. 2 represents an accurate drawing of one of the bones of 
the skull which has participated in the formation of the greater fonta- 
nel, the plate of bone haiing increased in a given time by one line 
all around from its original size, as in Fig. 1. 

So long as the borders of the sutures continue to grow in the same 
proportion as the borders of the fontanels, the steady enlargement 
of the fontanel naturally will continue. But a period arrives when 
the borders of the sutures become ossified, forming seams, in a more 
limited sense, and the entire head at the same time enlarges at 
a slower rate. The result of this is, that the bony margins cannot 
further separate or be displaced, and that the unchecked continued 
growth of the ununited fontanel-borders has for its object the gradual 
diminution of the fontanel. The period of the simultaneous forma- 



REMAEKS UPOX THE INFANTILE ORGANISM. H 

tion of the sutures, and the diminution of the fontanel, in healthy 
childi-en, occurs about the ninth month. The fontanel does not, 
however, become completely closed till after the fifteenth month. 

Tlie enlargement of the greater fontanel in the first three trimes- 
ters is, therefore, neither pathological, nor rachitic, but a physiolog- 
ical condition. 

The purpose of the greater fontanel is considered in a one-sided 
manner, from its negative point of view only, deficiency of firm ossi- 
fied covering, while its form, position, increase of size, taken in 
connection with the whole development of the child, show an actual, 
positive purpose. 

The skull and spinal column together form a firm, unyielding 
casing around the brain and spinal cord, so that the contents of the 
skull and the spinal canal can neither increase nor diminish in volume. 
Now in the first year of Hfe, when the brain grows rapidly and is 
more predisposed to congestion than subsequently, an absolute fixation 
of the skull would not allow this physiological growth, consequently 
the greater fontanel exists as an elastic point, acting very much in 
the manner of a safety-valve. 

V^Tiile in congestion of the brain, and hydrocephalus, it bulges 
and arches outwardly, and thus lessens the pressure of the plethoric 
vessels or hydrocephalic efi'usion upon the brain, in cerebral anaemia 
and atrophy of the brain it arches inwardly and forms a depression 
on the top of the skull. 

The brain grows most rapidly in the first months of life ; at birth, 
it weighs less than one pound ; in the second year nearly one and a 
half pounds. In the new-born, the cerebral substance is soft, almost 
homogeneous, and is not well defined into gray and white, or cortical 
and medullary substance. In the first year the dura mater is always, 
in the second quite frequently, firmly adherent to the calvarium, so that, 
in opening the skull, the dura mater has to be removed simultaneously 
with the calvarium. It therefore seems superfluous to describe this 
phenomenon as peculiar in the autopsy of every child under one year 
of age, as is the case in most reports of autopsies, in which also a 
special amount of stress is laid upon it. 

TEE EEUPTION OF TEE TEETS. 

The formation of the teeth, according to Syrtl, begins as early 
as the first third of embryonic life. In the sixth week of pregnancy, 
according to Goodsir^ narrow little grooves form at the future site 
of the maxilla between the barely-recognized lips and the rudimentary 
arch of the jaw. The margins of these grooves increase to ridges, by 



12 DISEASES OF CHILDREN. 

which the fissures are converted into excavations or inlets. At the 
bottom of these inlets little roots spring up, between which the 
curved ridges dip down and form cells for the roots. Every cell 
communicates with the mouth by an opening w^hich, through the 
convergence of its borders, subsequently becomes closed. Thus 
the dental sac originates, and in its depth the dental papilla is 
implanted; The dental papilla serves as a nucleus for the deposit of 
the tooth-substance (cementum), the enamel being formed by the 
enamel germ, w^hich crowns and envelops the head of the papilla, and 
into which the latter grows. In this manner the dental sacs of the first 
twenty teeth are developed, their ossification following in the fifth 
month of intra-uterine life. The sacs for the permanent teeth sprout 
on the posterior walls of the deciduous dental sacs, probably w^ith 
hollow communications. By increasing growth they become cut off 
from these, but still hang to them by a thread-like attachment (gu- 
bernaculum dentis). All the sacs of the milk and permanent teeth 
are present in the maxilla of the new-born. The deciduous teeth 
in time grow upward tow^ard the alveolar borders of the jaw, 
which is closed by cartilage. The cause of this upward growth is 
the successive development of the dental root. The cartilage of the 
gum and the upper wall of the dental sac disappear simultaneously. 
And the lateral walls of the dental sac become the periosteum of the 
dental root. Sometimes the cartilage disappears before the crown of 
the tooth has reached the upper surface ; the erupting tooth then lies 
freely exposed in a shallow depression of the gum ; often, however, it 
cannot be seen, but only felt, and is discovered by striking upon it 
w^ith a spoon-handle — an experiment which may give much pleasure 
to the parents who are impatiently waiting for the appearance of the 
first tooth. 

Attended by increased secretion and redness of the mucous mem- 
brane of the mouth, and various other symptoms to be treated of in 
the special part, the eruption of the first milk teeth begins. In the 
majority of healthy children the tw^enty deciduous teeth appear in 
the following five groups : 

Group I. — Between the fourth and seventh months of life the two 
lower middle incisors appear almost simultaneously, whereupon a 
pause of three to nine weeks ensues. 

Group II. — Betw^een the eighth and tenth months of fife the four up- 
per incisors appear, foUow^ing shortly upon each other. At first 
the two central, then the two lateral. The second pause amounts 
to from six to twelve weeks. 



REMARKS UPON THE INFANTILE ORGANISM. I3 

Gkoup III. — Between tlie twelfth and fifteenth months of life six teeth 
appear at once, namely, the four first molares and the two lower 
lateral incisors ; generally the molares in the upper maxilla first, 
next the lower incisors, and lastly, the molares of the lower jaw. 
A pause until the eighteenth month now ensues. 

Gkoup IV. — Between the eighteenth and twenty-fourth months of life 
the canine teeth cut through (the upper ones are called eye-teeth). 
Again a pause until the thirtieth month. 

Gkoup V. — Between the thirtieth and thirty-sixth months, the second 
four molares finally make tlieir appearance. 

This concludes the first dentition. The child has now twenty 
milk-teeth. In the fifth or sixth year of life the first molares cut 
through, and with them the second dentition begins. The arteries of 
the deciduous teeth become obliterated and their nerves disappear, 
and as they are thus deprived of their vitality they become loose by 
the enlargement of the alveoli and finally fail out without pre- 
viously becoming carious. As the infantile maxilla is not large 
enough to allow the permanent teeth to be developed in a single 
row, the permanent canine, is therefore compelled to grow in front 
of the external incisor and first molar, and to this remarkable situation 
of the canine tooth is also frequently due its faulty position after it has 
cut through. The partition wall which separates the alveoli of the 
permanent teeth from those of the milk-teeth is after awhile ab- 
sorbed. In order that the first may follow the latter, and that they 
may not grow amiss, the constricted cord between each milk-tooth 
and the corresponding permanent tooth is again transformed into an 
open passage. The milk-teeth fall out again in about the same order 
as they appear. In the twelfth year the fourth molar appears, and 
finally between the sixteenth and twenty-fourth year the fifth molar, 
also called wisdom-toothy the crown of which does not begin to ossify 
till the tenth year. 

" Although it cannot be maintained that all healthy children cut 
their teeth in the above-described order and time, yet this much is 
certain, that those children who follow this order suffer the least from 
the difficulties and sequelae of dentition. Under the irregularities 
of physiological dentition the following observations in particular may 
be made. (1.) Irregularity in time; Children sometimes come into 
the world with teeth, as Louis XIV. and Mirabeau, without subse- 
quently having a quicker general development. (2.) Irregularity in 
succession : Occasionally the upper incisors appear before the lower, 
and in such cases the lateral generally before the central ; very rarety 
do the canine appear before the molares. 



14 DISEASES OF CHILDREN. 

CHAPTER II, 

GENERAL RULES FOR THE EXAMINATION OF CHILDREN. 

Veet small children, only a few weeks old, are very indifferent 
to a professional examination; they sleep much, and feel so com- 
fortable when relieved of the firm bandages * for a little while, that 
they are rarely restless and unquiet. But when they once begin 
to recognize and distinguish surrounding objects, as is often the case 
with children three months old, every strange face frightens them, 
therefore also that of the physician who is called in to attend them. 
In some children this timidity lasts only till the eighteenth or twenty- 
fourth month ; sometimes it decreases, sometimes again it increases, 
in others it persists till the fourth or sixth year. Much depends, how- 
ever, upon the circumstances under which the child grows up ; it will 
be the more timid, the fewer persons it has an opportunity to see ; 
children that grow up in the city are, therefore, less timid than those 
reared in the country. 

There are three circumstances which act as obstacles to the child's 
physician : the absence of speech, the marked agitation which the ex- 
amination always induces, and, lastly, the crying which often ac- 
companies this agitation. The first obstacle, of course, cannot be 
removed ; it may, however, in a measure be replaced by a well-directed, 
comprehensive interrogation of those in charge of the child ; the last 
two, on the contrary, must be avoided. 

When a child has been washed, and nursed, or fed, it generally 
falls asleep ; and, as these necessities in respectable families are at- 
tended to at about the same time every day, it is therefore very easy 
to observe and examine the child while asleep, and for this purpose 
it should be dressed in such light garments as will not necessitate its 
disturbance in removing them. Its sleeping is favorable for that 
examination which can only be fully appreciated when carried out 
with the utmost quietness — that part of the examination which can 
be made regardless of the agitation and crying may be deferred till 
the child is awake. From this it follows that the examination of sick 
children must be undertaken at two separate periods of time, namely, 
during its rest and during its agitation. The expression of the coun- 
tenance, the attitude and involuntary motions of the body and ex- 

* In Germany, and most of the countries of Europe, the entire body of the infant 



RULES FOR THE EXAMINATION OF CHILDREN. 15 

treniities, tlie pulse, the kind and number of the respirations, and the 
results of auscultation, can only be properly noted during rest. The 
skin, its color, temperature, and morbid alterations ; the mouth, the 
abdomen, genitals, anus, the extremities, the manner of nursing, and, 
above all, the cry, may be examined during the agitation. 

The expression of the countenance betrays the sensations of even 
the youngest infants tolerably distinctly, and may greatly aid the 
experienced observer in the recognition of diseases and the formation 
of a . prognosis. Eiisehe de Salle very correctly observes that the 
healthy nursling has a totally expressionless physiognomy, in which 
every one, a mother perhaps excepted, must agree with him. The 
fact is all the more important, that sick children have a certain ex- 
pression of countenance, in great part due to the disappearance of the 
adipose tissue from the subcutaneous tissues; in part, however, 
this is due to a peculiar contraction of the otherwise relaxed facial 
muscles. 

The expression of the countenance of a previously healthy, robust 
child becomes so rajoidly changed in every profuse diarrhoea, and espe- 
cially in Asiatic cholera, that it is often barely possible to recognize it 
again in twenty-four hours. The eyeballs sink back into the orbita, 
so that the lids are scarcely able to cover the bulbs, and a fold (corre- 
sponding to the lower border of the orbit) forms in the lower eyelid ; 
the nose becomes pointed, and the previously plump, ruddy lips be- 
come sharp and thin. 

In chronic atrophy, also, the last traces of adipose tissue disap- 
pear from the face ; the integument everywhere becomes loose and cor- 
rugated, and, in addition, various contractions of the muscles take place, 
as a result of cerebral irritation, especially that of the frontal, next of 
the corrugator supercilii, and the levator alee nasi et labii superioris 
muscles, by which the face acquires a senile appearance, and, on ac- 
count of which, the French Pasdiatricars, in a very ungallant manner, 
call it a Voltairian face. 

Jadelot has described three expressions of the countenance, which 
he claims indicate the existence of internal diseases. The first expres- 
sion begins at the internal angle of the eye, and becomes lost upon 
the zygomatic process. He calls it " le trait oculo-zygomatique." 
The second starts from the upper part of the wing of the nose and sur- 
rounds in a semicircle the external border of the orbicularis oris. This 
divides into two parts, into the nasal-expression (le trait nasal), and 
into that of the cheek (le trait genal). The third expression begins at 
the angle of the mouth, and becomes lost toward the chin. The first, 
it is claimed, denotes affections of the brain; the second, affections of the 



le DISEASES OF CHILDREN. 

abdominal ; and the third, those of the thoracic organs. It is scarcely 
necessary for us to suggest to the reflecting physician that this is mere 
fantasy. Alas ! it will not be made so easy for the physician to recog- 
nize and diagnose a disease by merely inspecting the face. But there 
is one single sign characteristic of a certain disease found in the face, 
namely, the rising of the alse nasi with every inspiration, by which 
we are able to diagnosticate, with the greatest certainty, an inflam- 
matory affection of the lungs. 

As regards the attitude and movements of the child, the new-bom 
is always apt to assume that bodily position which it occupied within 
the uterus. The back is bent a little outwardly, the head flexed upon 
the chest, and the limbs are bent upon the body. When a child 
lies quietly, sleeps soundly and uninterruptedly, and is tolerably 
active when awake, then it may be satisfactorily concluded that it is 
in excellent health. There is a decided contrast between this state 
and the condition of powerlessness and stupor. In the former the 
mobility of the child is abohshed, it lies then apathetic ; in the latter, 
on the contrary, the eyes are staring, and follow no more the eyes of 
the mother, or of the nurse ; as is the case even with very small, 
healthy nurslings, of but fom- weeks old, the eyelids cover only half 
of the cornea, and do not become completely closed even during 
sleep. 

If children throw themselves about unceasingly, and find no rest 
in any position ; when they have a heightened tempreature of the 
skin, with an accelerated pulse, and then become tranquil without any 
diminution of the fever having taken place, this remission is only the 
result of increasing weakness, and may be regarded as an unfavorable 
sign. In exudative affections of the brain, children often flex the head 
backward ; in cerebral atrophy, as a result of general atrophy, they 
will constantly rub the occiput on the pillow, or bore the head into it, 
and with their httle hands pull their hairs and ears. Healthy children, 
when tired, faU asleep in any posture and quietly continue to do so ; 
but in pneumonia, in most instances, they choose the dorsal decubitus, 
or lie on the affected side, and will immediately turn over if they 
happen to be placed upon the unaffected side. Children with scrofulous 
inflammations of the eyehds, and sometimes those with cephalic pains, 
lie upon the face. 

AVhen infants during nursing, or shortly after that, are laid upon 
the left side, they generally become restless and begin to vomit ; this 
is apparently owing to the enormous size and weight of the liver, which 
ill this position presses upon the stomach. For that reason also do 
nurslings suck ^vith more ease at the left breast, for, being oftener 
put to this one, more milk is usually found in it thaii in the right. This 



RULES FOR THE EXAMINATION OF CHILDREN. 17 

argument is quite probable, from the fact that nurslings who obsti- 
nately refuse to suck at the right breast will very often take it with- 
out any objection as soon as their lower extremities have been put 
under the mother's right arm and they are allowed to nurse while 
lying upon the right side. 

Children frequently point directly to the site of the pain with the 
hands. During dentition they feel about in the mouth, in hydroce- 
phalus and cerebral irritation they will pull at the hairs (but some- 
times also at the genitals), and in croup they press and rub themselves 
about the neck ; older children, when suffering from colic, press with 
their hands upon the abdomen, or when suffering from pain in the 
bladder, which is often caused by vesicants, upon the organ. When 
affected with worms, they will pick and bore at the nose and anus. 
Atrophic children keep their thumbs drawn inward and the hands 
shut firmly. The flexing and extending of the lower extremities by 
starts and jerks, attended by crying, are the ordinary signs of flatulence, 
and cease as soon as the flatus has been discharged. 

The examination of the pulse can only be carried out with success 
in a sleeping child. In one that has waked up suddenly, or has be- 
come agitated through much handling, the physician will find that he 
has to battle with insurmountable difficulties. The child seeks in 
every manner to twist itself loose from liis grasp, and the firmer the arm 
is fixed, the tenser does the child make its muscles, and it often be- 
comes wholly impossible to feel the pulse. 

Various measures have been suggested by which we might be 
enabled to feel the pulse in a child, such as to allow it to suck at the 
breast or bottle. But the act of sucking always accelerates the 
respiratory and the cardiac actions, and for this reason no useful 
information whatever can be obtained by this method. It is best, 
therefore, to quietly approach the child while asleep, lightly com- 
press the radial artery with the end of the index-finger, and, when 
it moves its arm, accompany it in aU its movements without the least 
resistance ; after the removal of the fingers the child usually sinks 
again into a sound and lasting sleep. But if the restlessness of the 
arm continues, the examining finger should be withdrawn, because 
otherwise the child will surely be awakened, and no time is so unfa- 
vorable for examination by the physician as that after awaking 
from sleep. The neglect of these precautionary measures wiU doubt- 
less serve to explain the reason why most authors state the pulse 
of the nursling infant to be so high, 130 to 140 beats per minute. 
Valleix, physician to the Foundling House at Paris, has found the 
medium of the pulse in thirteen healthy sleeping nurslings, from 
three to twenty-one days old, to be 87 (minimum 76, maxiiliuni 104). 
2 



18 DISEASES OF CHILDREN. 

In twentj-four healthy sleeping nurslings, I found the minimum 92, 
maximum, 136, medium, 109 per minute. It is stiU more difficult, on 
account of the smaUness of the artery, to discriminate between a 
hard and a soft pulse. Undoubtedly, our chief attention in nurs- 
lings should be directed to the rhythm of the pulse ; an unrhythmi- 
cal, interrupted pulse occurs in cardiac aifections and cerebral dis- 
eases. Great frequency of the pulse-beats in children has much less 
significance than in adults, for that condition is induced by the least 
excitement and the most trivial pain. Slowness of the pulse is ob- 
served in sclerema of the new-born, and in cerebral compression. In 
many instances before death the pulse is altogether imperceptible for 
one or several days. 

The examination of the respiratory organs in small children is 
attended by the greatest difficulties, occasioned as much by the 
smaUness of the affected organs as by the restlessness and refractori- 
ness of the child. The physical examination embraces inspection, 
percussion, auscultation, and palpation, the first two of which can 
only be performed during perfect quiet, but the last two even in cry- 
ing children. 

Inspection. — First of aU, as regards the number and kind of respi- 
rations in children who have not yet passed the first year of life, 
it appears, from the very positive statements of the most conscientious 
authors, that upon this point no definite normal numbers can be given. 
These statements fluctuate between eighteen and thirty-five respira- 
tions per minute. Above aU, we must remember that the respira- 
tions, even of healthy children, are not alike during sleep and wake- 
fulness. Only during sleep is respiration performed in a perfectly 
regular and rhythmical manner. Sixty experiments, which I instituted 
in twenty-two sleeping children from three to four weeks old, gave 
me, as a medium, 26.4 inspirations per minute. As soon as the 
children are roused and have become somewhat lively, the respira- 
tions are changed by every touch, every unusual noise, and every 
change in the light of the room ; the interval is longer than usual, and 
is followed by a few short, very quick or deep and slow breathings ; and, 
if the children now begin to cry at aU, the rhythm will be entirely 
abolished ; in general, however, the respirations increase in frequency 
during crying. Owing to this great physiological variation, no 
diagnostic conclusion can readily be arrived at from any smaU devia- 
tions from the medium number. 

In children who have passed the first year of life, the respiratory 
acts are more uniform in the wakeful state. In pulmonary affec- 
tions, which occur extremely often in childhood, particularly lobular 
pneumonia and rachitic carnification, the breathing is accelerated 



RULES FOR THE EXAMINATION OF CHILDREN. 19 

from two to four fold, consequently to fifty or eighty in the minute, 
without any mechanical hinderance, solidification of large portions 
of the lungs with exudations being physically demonstrable. In later 
years, after the completion of the second dentition, certain diseases 
only abolish the rhythm, especially all those cerebral affections which 
are capable of exercising a serious pressure upon the cerebral substance, 
above all, acute hydrocephalus ; furthermore, large cerebral tubercles, 
carcinoma of the brain, and sometimes also meningitis and cerebral 
haemorrhage, if the amount of pus or blood upon the meninges has 
attained to a certain quantity. In these cases, the respiratory acts 
are remarkably irregular, alternately retarded and accelerated, deep 
or sighing. 

As regards the respiratory actions, we have in the healthy child 
abdominal respiration predominant, i. e., the diaphragm contracting 
stronger and firmer than the muscles of the thorax ; the upper part 
of the chest is almost entirely undistended ; the lower portion, how- 
ev^er, is all the more markedly expanded, so that more of a change of 
form of the abdomen takes place than of the thorax. The manner of 
breathing varies greatly in various pectoral diseases ; the various de- 
viations ^vill more appropriately be spoken of in connection with the 
individual diseases. A careful inspection of the thorax is very im- 
portant, and often supplies many clews, even before the actual phy- 
sical examination has been commenced, which, on the whole, in the 
restless condition of the child, is often unsatisfactorily accomplish- 
able. 

Percussion of the infantile thorax is best executed without a 
pleximeter or hammer, finger upon finger. The excellent rule in 
surgery, to avoid using all instruments that can be replaced by the 
hand, is here all the more applicable, as children, especially those 
between two and three years of age, have an insurmountable dread 
of the hammer and pleximeter, whereas by gentle and tender man- 
agement they will readily allow themselves to be percussed with 
the fingers. Children carried about upright are best percussed in 
the arms of the mother. In these, the dorsal surface, upon which 
the greatest attention is to be bestowed, offers itself most conven- 
iently, and the youngest children most readily submit themselves 
to be percussed when they are in direct contact with their mother. 
Young infants should be percussed in the lateral decubitus, from wliich 
little opposition will seldom be encountered. That the hands should 
be warmed before they are laid upon the naked body of the child, is 
self e\ident. Physicians who suffer from cold and moist hands will 
not particularly succeed in the children's practice. 

The percussion-strohe should he made ahsolutehj softly, ^f;^^'/?/, 



20 DISEASES OF CHILDREN. 

and slowly, and should he continued long enough on one spot until 
there has been a chance to percuss in the moment of the deepest inspi- 
ration and most compjlete expiration y for this purpose, ten and even 
more blows will often be requisite. 

A forcible percussion, such as is requisite on the back of an ath- 
letic adult, is, on account of the elasticity of the thorax and the smaU- 
ness of the organs to be examined, never allowable in children. The 
percussion is not made plainer thereby, but other parts, generally the 
intestines, are made to resound ; and, besides, the child is instantly 
and surely frightened by strong blows. 

Percussion should be performed slowly, because the examiner 
always requires a certain amount of time to appreciate the sound 
produced, and to form an opinion of it. The most experienced 
ear is unable to detect the finer variations of the sound produced 
by the usual rapid thumpings. 

The same place is to be percussed until the deepest inspiratory 
and expiratory moment is caught, because only by comparing and 
properly estimating the two percussion-sounds thus obtained, and 
which always differ from each other, is a thorough investigation of 
the percussed part possible. 

I must call special attention to a phenomenon which, in spite of 
its daily occurrence, has nowhere yet been properly estimated, and 
still less satisfactorily explained, namely: when both lungs of a 
healthy child are percussed by way of comparison on the back, from 
birth up to the second and even the third year, there is found on both 
sides, so long as the child breathes calmly, and makes no noise what- 
ever, a sonorous, feeble, or strong tympanitic percussion-sound; as 
soon, however, as it becomes disturbed or restless, or when it resists 
the examination, and proclaims its unwillingness by a pressing out- 
cry, then the whole condition is suddenly changed. Instead of the 
equal sonorous tympanitic sounds of both sides, a moderately duE 
percussion-sound prevails over the left lung, and a flat, empty 
sound over the right lung as far upward as the spinae scapulae. 
But, if the percussion is now quietly continued on the same spot 
some seconds, or even for minutes, till it happens that a percussion- 
stroke coincides with the moment in which the child again inspires 
deeply, and, for that purpose, has to abandon the abdominal pressure 
till the completion of the respiratory act, the original normal percus- 
sion-sound is suddenly heard again ; it, however, lasts but a few 
moments, and is instantly succeeded by an empty, flat sound. 

If the percussion has once disturbed the child, and especially if 
it does not cease to cry with the violent abdominal pressure, and, 
so long as this pressure lasts, the phenomenon just described may 



RULES FOR THE EXAMINATION OF CHILDREN. 21 

be studied with the utmost advantage in any child under one year 
of age. 

The proximate reason for this diminished sonorous sound upon 
the entire dorsal surface is owing to the abdominal pressure, whereby 
the whole contents of the abdomen are compressed upward. The 
difference between the right and left sounds, namely, the completely 
empty, flat percussion-sound on the right, is explainable by the 
strong upward pressure of the liver, the size of which is still dispro- 
portionately greater in comparison with the rest of the abdominal 
organs. 

Upon the anterior surface of the thorax, and also on both sides, 
the changes in the percussion-sounds, originating from the action 
of the abdominal pressure, are also noticeable, but in a much less 
striking- deo-ree. 

The singular phenomenon just described, namely, the complete 
dulness posteriorly toward the right side, causes my confidence to be 
somewhat shaken in the histories of pneumonia in small children that 
we find so frequently in text-books and journals; and the more 
so, as the dulness in those cases is always described to have been 
most intense posteriorly on the right side. Such physical investiga- 
tions only can be relied upon in which it is expressly stated that, 
during the investigation, the child respired perfectly calmly and 
quietly ; that it did not employ the abdominal pressure, and that the 
dulness detected then was also present during the inspiration, and 
could be distinctly discerned for several days. I am convinced that 
attacks of bronchitis, which in the first days of their existence are 
attended by some fever and dyspnoea, are regarded as cases of 
pneumonia in consequence of the observer's not being aware that 
the dulness which, under the circumstances described above, appeared 
on the right side posteriorly, is a normal physiological condition y 
this may also explain the successful treatment of and rapid recoveries 
from pneumonia. 

There is another phenomenon to be noticed in percussing the 
thorax of a crying child, namely, the so-called metallic tinkling. This 
sound a person may study upon himself at any time, by striking the 
sternum with the shut fist, and at the same time singing loud notes. 
The tone is thus momentarily interrupted by a sound that has a metal- 
lic clang, and a pitch the same as the tone sung, which, directly after 
the blows have occurred, rings out in its original purity. Tliis sound 
cannot be confounded with cavernous metallic tinkling, and the hndt 
de pot file occurring in the adult, as it can only be produced during 
crying or speaking, whereas that arising from cavities is heard even 
when the patient does not utter the least sound. Metallic tinkling is 



22 DISEASES OF CHILDREX. 

never met ^ritli in cliildren who respii^e quietlj, for, in the first place, 
cavities in children under two years of age, as is well known, are 
of extremely rare occmTcnce, and in the second, even if thej do exist, 
this sound can only exceptionally be detected by percussion. No 
diagnostic importance can therefore be attributed to it. 

The size of the thjTHus gland may be ascertained by percussion. 
If the manubrium sterni is carefully and slowly percussed as sharply 
as possible, a dulness will be detected, which decreases in circumfer- 
ence from month to month. By this examination the physician can 
n*equently convince himself that many children have a large thymus 
gland, and yet never suffer from spasm of the glottis, and also that, in 
many children who suffer from violent spasm of the glottis (or what 
has been called asthma thjTaicum), a thymus gland cannot be found 
on percussion. 

Auscultation, in adults the most important part of the physical 
examination, offers in children fewer advantages, partly on account of 
their constant restless condition and irregular breathing, partly owing 
to the smallness of space and the propagation of the sound, favored as 
it is by the elasticity of the thoracic walls, and lastly from the fact 
that the infantile voice can neither be called into action nor suppressed 
at the wish of the examiner. 

In emaciated children, when the intercostal spaces present marked 
depressions, it is altogether impossible to adapt the stethoscope accu- 
rately, and hardly any child tolerates the auscultation of the anterior 
or lateral surfaces of its thorax with the naked ear, therefore it only 
remains for us to auscultate the back. But while in the adult we 
definitely know the space that is bounded by tracheal respiration, 
in children this is not the case. In healthy children we hear over the 
entire back, often even over the entire thorax, a loud eDijnration and 
a tubular inspiration, so that, although this condition, when met with 
in an adult, would make us imhesitatingly affii-m an extensive con- 
solidation of the pulmonary tissues, yet it would not in children. We 
have not in these auscultations both the strongly-defined sounds of 
normal vesicular respiration, and the bronchial respiration, but over the 
greater part of the thorax a sound very much like bronchial breathing, 
and difficult to distinguish from it. Thus the main conclusion which 
in the adult we are able to form fr-om bronchial respiration, namely, 
sohdification of pulmonary tissue, is lost ; in children we have chiefly to 
depend upon a mere comparison of both thoracic moieties, upon which 
of the two it is most distinctly heard. Auscultation of the voice fur- 
nishes good cardinal points. The voice, it is true, consonates all over 
the infantile thorax, but where solidified pulmonary tissue exists, there 
it consonates so forcibly that the examiner beheves he holds his ear 



RULES FOR THE EXAMINATION OF CHILDREN. 23 

against the moutli of the child, and that it cries directly into it. This 
sign is all the more valuable, as it is available in crying children, and 
therefore does not necessitate any particular care or loss of time in 
examining the child. 

Palpation is the simplest and most convenient method of exam- 
ining the infantile thorax. When the hand is laid upon the chest 
of a child, the temperature and moistness of the skin are immediately 
appreciated. Since thermometric measurement, owing to the restless- 
ness of children, is not applicable, in private practice in particular, 
it is therefore necessary for the physician to become accustomed to 
judge of the temperature of the skin as accurately as possible by the 
hand alone, for augmented temperature is the most important of the 
group of symptoms which we call fever, and our therapeutic pro- 
cedures in a great measure are conducted in accordance with it. 

Besides the above general advantages, the hand that is laid upon 
the chest also feels the fremitus of the voice, i. e., the vibrations of 
the thorax communicated to the hand, which originate with the voice, 
and disappear again as soon as it ceases. These vibrations are most 
strongly felt at the spot where they originate, over the trachea and 
larynx, very distinctly along the spinal column, in the space between 
the scapulae, plainly in the lateral regions, and over and above 
the clavicles and the sternum. Where the heart and liver are in 
direct contact with the chest, the fremitus is completely arrested. 
Layers of adipose tissue also weaken the vibrations. 

Now, these phenomena occur in every healthy child, but become 
modified as soon as a part of the pulmonary tissue undergoes solidifi- 
cation by compact tubercles or scirrhous infiltration, lobar hepati- 
zation or carnification. WTien, in the above afi"ections, the larger bron- 
chi, terminating in the solidified parts, remain permeable, the voice is 
felt 77iuch stronger than in health. Occlusion of a bronchus abolishes all 
fremitus over a corresponding portion of the lung. Fluid efiiisions into 
the pleural sacs, where the liquid keeps the lung from the ribs, also 
hinder us irom. feeling the voice. On the other hand, in the compres- 
sion of the lungs that necessarily results from that condition, the fre- 
mitus is much augmented over those parts of the thoracic walls 
against which the compressed lungs lie. 

In addition to the voice, the rhonchi may also be elicited by pal- 
pation. If the tenacious masses of mucus which fill the ti^achea and 
bronchi in the form of lamellse or trabeculjB are set in motion by the 
respiration, a certain sound is produced, which is carried along the 
thoracic walls farther and more distinctly than any other. On this lat- 
ter circumstance is based the erroneous supposition that these sounds 
originate where they are most distinctly felt. The higher up toward 



24: DISEASES OF CHILDREN. 

the trachea the vibrating mucus is situated, the more diffused are the 
sounds produced thereby felt over the thorax ; the smaller the calibre 
of the bronchus containing the mucus, consequently the nearer the 
periphery of the lung, the more circumscribed will the sound be on 
the thoracic walls. 

Palpation of the voice and rhonchi should never be omitted, and in 
restless children must even take the place of percussion and aus- 
cultation. 

These are the main points to which the physician has first to direct 
his attention in the sleeping or at least in the quiet child. Percussion 
should always be the last thing to perform, because by it the child is 
apt to be waked from its sleep. 

The examination of the abdominal cavity is perhaps still more im- 
portant than the examination of the thoracic, for in early life diseases 
of the intestines are by far more frequent than those of the lungs and 
heart. If, in the adult, percussion of the abdomen gives no reliable 
results, on account of the fluctuating gas in the gut, in the child, where 
this is of such frequent occurrence, it is of still less value. In all kinds 
of intestinal catarrh, the bowel is tympanitic, and distended, so that 
the liver and spleen, on percussion, appear to have perceptibly dimin- 
ished in size. 

Valleix, when he desires to examine the abdomen of a child, causes 
it to be brought suddenly to a bright window or near a light, on 
which the restlessness, as a rule, instantly ceases ; the child is attracted 
by the light, and gazes at it steadily for some time. This moment 
must be made use of to make a slow, increasing pressure upon the 
abdomen, to which the child will calmly submit so long as the pres- 
sure causes no actual pain. In this manner the abdomen of the 
youngest child may frequently be pressed so firmly as to touch the 
spinal column. If the pressure is really painful, the child will utter 
an agonizing cry and distort its features, which sometimes directly 
ceases again as soon as the pressure has been removed. 

Serous effusions into the peritoneal sac, which occur principally 
after scarlatina and in tuberculosis of the peritonasum, is difficult to 
detect in the supine position. The serum then sinks back into the 
posterior part of the cavity and the intestines float upon the top of 
the liquid against the abdominal walls, so that fluctuation can nowhere 
be discovered. But if the child be allowed to sit up or to lie upon 
the belly, the serum sinks downward and forward, and is then easy 
to be detected by percussion and by fluctuation. 

The anus should be carefully inspected in every child. In every 
diarrhoea it becomes red, and forms a certain index of the severity 
and duration of the evil ; on it also usually appear the first symptoms 



RULES FOR THE EXAMINATION OF CHILDREN. 25 

of congenital sypMlis. The internal examination is not attended by 
any difficulties whatever ; the little finger well oiled is readily intro- 
duced by a slow, rotatory motion, but this procedure always causes 
pain, and should only be performed when actual indications for it exist. 

The genitals also deserve, in all cases, to be closely scrutinized. 
They are reddened in diarrhoea, and the scrotum especially exco- 
riates very rapidly; and the female genitals secrete a larger quan- 
tity of mucus. The simplest manner of examining the urethra is 
by introducing a silver probe, bent hke a catheter, for boys, which pro- 
cedure is of service, as a remedy in many cases of strangury. 

The inner surfaces of the thighs are the best indices for judging 
of the fleshiness of a sick child. An indisposition, and particularly 
a diarrhoea of several hours' duration, makes the formerly firm, tense 
integument soft and somewhat lax, in twenty-four hours small folds 
form in it, and, if the disease continues, the adipose substance disap- 
pears so completely that, in place of the former symmetrical con- 
dition, flabby folds form, which, however, as the nutrition improves, 
fill up again surprisingly quick, and the inner surfaces of the thighs 
once more display their former shape and sohdity. 

The examination of the mouth should never be omitted. By 
pressing slightly upon the chin the child wiU usually open the mouth, 
or a finger may be introduced and carried slowly backward between 
the cheek and gums, till it reaches the anterior border of the ascend- 
ing ramus of the lower jaw ; here the finger is insinuated between 
the upper and lower maxiUse, and now the mouth may be opened to 
the required extent. By a little adroitness and practice it is very 
easy to examine with the index-finger the posterior pharyngeal wall, 
the posterior nares, the epiglottis, and even the glottis itself; such 
an examination will often give much important information in certain 
cases of diphtheritis, retropharyngeal abscesses, croup, etc. 

The tongue, in children, is even less " the mirror of the stomach " 
than in adults. Children with severe intestinal diseases very fre- 
quently have a perfectly normal red tongue, and conversely healthy 
children with a good appetite and regular digestion often exhibit a 
very white, or, at least, a tongue spotted with islands of white fur. 
Many parents so train their children from the earliest age, that they 
wiU put out the tongue whenever ordered, and accomplish some good 
by their obedience. The young ones, however, carry their good 
breeding so far, that they constantly put out their tongue, even 
upon the street, for the family physician, whom they often recognize 
at a distance, and to the general amusement of the passers-by. 
Teething children with swollen gums allow their mouths to be exam- 
ined very unwillingly, it is therefore necessary to become accustomed 



26 DISEASES OF CHILDEEN. 

to examine both jaws as rapidly as possible by one sweep of the fin- 
ger, so that they may not thereby be irritated and disquieted. 

Finally, there are two sounds which we have to note in the exam- 
ination of children : the cry and the cough. 

Children cry only during the expiratory act. During inspiration, 
it is true, some single sounds occur, for instance, in spasm of the 
glottis. But these loud, long-dra^vn inspirations are always single, 
and, properly speaking, cannot be included in the description of 
" cry," for by this w^e understand a succession of tones quickly fol- 
lowing each other. The ordinary cry, therefore, takes place only 
during expiration ; it is loud, ringing, long-drawn, and, in children 
of equal age, of tolerably equal pitch : still the tone of the cry has, in 
almost every child, something peculiar, which cannot be more accu- 
rately defined than the variations of the human voice. A momentary 
disturbance of the circulation must always ensue during crying, be- 
cause the air in the lungs becomes compressed by the abdominal 
pressure, and can only escape slowly through the tense glottis, and 
not in comparison to the degree of its compression. After a deep 
inspiration, the child begins its cry by opening the mouth wide, 
when the tongue may sometimes be seen moving about in slight con- 
vulsions over the margins of the gums, the alse nasi become dilated, 
the eyes tightly closed, and numerous wrinkles form upon the cheeks 
and forehead, the face gTowing constantly redder, its veins, as well as 
those of the neck, become turgid, and the cry is prolonged to the 
utmost without renewing the inspiration. When this period arrives, 
it rapidly takes a deep inspiration, and thus brings about a momen- 
tary remission of the distortion of the countenance. These distor- 
tions last as long as the child continues to be agitated ; but, when it 
becomes pacified, the inspirations and expirations become uniform 
again, the wrinkles disappear from the face, a few slight short cries 
follow, the mouth gradually becomes closed, and a slight exhaustion 
follows, which generally terminates in a calm sleep. Sometimes, 
three or four cries, in rapid succession, in one expiration, are fol- 
lowed by one long-dra^v^Ti cry, which terminates in quivering strains. 
This cry has a great similarity to the bleating of the goat. It may 
also be remarked here, that infants under three months of age (and 
to these only is the preceding description applicable) never shed 
tears. 

The most important conclusions, as to the nature of the disease, 
to be dra^vn from the cry, are the following : children who suffer from 
pneumonia, pleuritis, or atelectasis of the lungs, never cry loud^ or 
continuously ; they can only emit a low, painful moan. Chil- 
dren afflicted with catarrhal, diphtheritic, or croupous laryngitis, 



RULES FOR THE EXAMINATION OF CHILDREN. 27 

are unable to crj at all, tliej are aphonic ; the milder degrees of ca* 
tarrhal inflammation of the larynx do not completely supjDress the 
cry, but make it hoarse. Hydrocephalic children utter only shrill 
tones, and after each outcry relapse into their former drowsiness. A 
child ill with fever never cries continuously nor long, even when it 
suifers violent pains. Childi^en suffering from otitis, deep abscesses, 
or when Avounded, cry the longest and most violently. 

In the cough we have a very important index by which to judge 
of the state of the respiratory organs. If the child coughs loosely, 
loud, and without pain, it is very certain that we have only a simple 
bronchial catarrh to deal Avith ; if, however, it distorts the countenance 
when provoked to cough, if the cough is dry and low, and if it seeks 
to suppress it as much as possible, then it is equally as certain that 
we have to deal with an inflammatory afi'ection of the lungs. Croup 
begins with a dry, barking cough, which but too soon gives place 
to a low aphonic sound. Pertussis consists of a long, spasmodic, 
jerking cough, interrupted by a protracted, loud, and sucking inspi- 
ration. Tuberculous children, in most instances, have a dry cough, 
which recurs at short intervals day and night. The cough of typhous 
patients is, in comparison with the great morbid alterations which we 
physically demonstrate on the lungs and frequently find after death, 
very insignificant and without severity. 

These are the principal peculiarities which the physician has to 
take into consideration in the examination of a sick child. Now, as 
regards the conduct of the physician, the utmost patience and gentle- 
ness are indispensable in his intercourse with children. Those from 
one to three years old are always the most difficult to manage. 
Nurslings and children under one year are seldom very timid, and 
are easily quieted by some diverting noise. But older children 
often have an insurmountable shyness for every strange face. Such 
a cliild the physician must not approach immediately after enter- 
ing the room ; he should at first ignore the child's presence alto- 
gether ; should enter into a conversation with the parents or nurse, 
in a gentle voice, and finally gradually approach the child with 
some bright object, or with a piece of sugar. When at the bed- 
side, the child should not be immediately uncovered, its abdomen 
felt and squeezed, and the physical examination instituted. Some 
questions suitable to its age are first put to it, its playthings are 
admired, or it is told of some new ones, and promised to be pre- 
sented with them, etc., etc. ; in short, it is necessary to be on 
friendly terms with the child before the undertaking of a regular, 
thorough examination can be thought of. In this manner, however, 
it is almost always possible to quickly gain the friendship of the 



28 DISEASES OF CHILDREN. 

child. If, with a friendship formed in this manner, a little seriousness 
and energy are allowed to be blended, much more authority will 
thereby be acquired in a moment over the child than the parents 
ever thought possible. Children, under such authority, allow them- 
selves very quietly to be examined, readily lie down upon any side 
desired, take even the bitterest medicines without objection, and 
assist the medical examination in every manner possible. JSfever, 
and under no ciixumstmices, should the attempt he made to bring an 
unruly child into obedience by harshness, by firmly holding it, and 
still less even by a slight blow. Such measures not only cause greater 
fear, and give rise to violent crying, but the physician will thereby only 
bring upon himself the aversion and even hatred of most narrow- 
minded parents — the class that usually have boorish and unmanageable 
children. On the other hand, if the physician in such instances re- 
tains his equanimity and mild voice, the parents will feel most dis- 
graced by the ill-breeding of their children. They then sometimes 
punish the child so severely that the physician, from a medical point 
of view, has to interfere, and then he will have gained an humble 
and submissive patient. In general, the principle will hold good 
that the more seriously sick the child is, all the more easily wiU it 
permit itself to be examined. 

To the commencing practitioner, inexperienced in the Pasdiatria, 
these observations may appear insignificant and unimportant, but, 
when he has once conducted himself in accordance with them, he will 
perceive that without these details a successful treatment would be 
clearly impossible, notwithstanding aU his knowledge and skill in the 
methods of examination. 



CHAPTER III. 

NURSING AND CARE OF CHILDREN. 

The best nutriment for a new-born child is undoubtedly the milk 
of its own mother; if she cannot nurse, the milk of a wet-nurse ; and, 
if this is also unattainable, the milk of a domestic animal. 

In regard to the suckling of a child by its own mother, two ad- 
verse conditions are not infrequently met with, viz. : an inability of 
the mother to nurse ; and the existence of circumstances rendering it 
improper for her to do so. 

She cannot suckle, when she has insufficient or no milk, when the 



XURSING AND CARE OF CHILDREN. 29 

nipples are wanting or are malformed, or when local diseases of the 
breast, abscesses or carcinomatous nodules, exist. Whether a moth- 
er will have milk and be able to suckle her child, is, in primi- 
parse, difficult to prognosticate. The size and firmness of a breast 
form no positive guide for that. Often young, healthy women, with 
well-formed and apparently physiological breasts, have no milk, while 
in feeble women, with previously flat bosoms, it is often secreted plen- 
tifully, contrary to expectation. Pregnant women, from whose breasts 
much colostrum flows, will be best able to suckle the coming child. 
In regard to this secretion, Donne divides pregnant women into three 
classes : to the first belong those who have so little colostrum that at 
the end of pregnancy it is only possible to squeeze out a few drops 
from the glands. This colostrum microscopically contains only a few 
milk-globules, and only a small number of colostrum-corpuscles. A 
small quantity of milk-secretion should, then, only be calculated upon 
after the confinement. 

The second class comprises those women who, it is true, secrete 
much colostrum, which, however, has the very same properties as 
that of the first class. It is just as poor in milk-globules and colos- 
trum-corpuscles, and a plentifully-secreted, though thin, but non- 
nutritious milk may, with probability, be expected after delivery. 

But if, in the third class, the secretion of the colostrum at the end 
of gestation is rich, milk-white, and mixed with yellow streaks and 
lumps, and many milk-globules, and colostrum-corpuscles are present, 
then we may prognosticate, with tolerable certainty, that the preg- 
nant one is destined to suckle her child, and will secrete sufficient nu- 
tritious milk. 

Total absence of the nipples is seldom met with ; frequently, how- 
ever, a depressed nipple is observed, for which usually a too high 
corset, in which the space for the chest is too small, is to blame. 
After delivery it is too late to improve these depressed nipples, and 
the child will uselessly tire itself out in the attempt at extracting 
the milk, and finally ceases altogether; much, however, may be 
done for this condition during the last months of pregnancy. The 
women should be made to wear very loose garments, and once 
every day should put the bowl of a clay pipe over the nipple, and 
suck with the mouth at its stem, or, still better, the caoutchouc breast- 
pump may be employed. JBouchut suggests, if the woman cannot 
tolerate this manipulation, for another person to use the lips in the 
same manner as the nurse often draws the breast of the parturient 
woman. 

Lastly, those benign, hard nodules, which occm^ so frequently in 
girls and young married women, but which are perfectly painless. 



30 DISEASES OF CHILDREN. 

should not be confounded with carcinoma of the breast. They are 
totally harmless, and disappear completely in the first few weeks after 
parturition, soon after the nursing is in operation. 

The second condition, i. e., circumstances rendering it improper 
for the mother to nurse her child, is much more difficult to explain. 
Feebly and tenderly-organized women, at times, bear the suckling very 
w^ell, when they otherwise possess favorable external circumstances 
and the lacteal secretory function so necessary for suckling. In other 
cases, on the contrary, nursing acts upon strong, robust women, when 
poverty, anger, grief, or unhappy matrimonial circumstances, become 
added thereto, extremely unfavorably; they become emaciated and 
grow old remarkably early. Those mothers must absolutely be forbid- 
den to suckle their children, who suffer from arthritis, epilepsy, syphilis, 
chronic cutaneous diseases, and tuberculosis, or even if they have only 
an hereditary disposition to them. In hysterical women, wet-nursing 
has, by virtue of the extraction of the vital fluids, not only an injurious 
influence upon the health of the mother, on account of the influence 
of the nervous system on the secretion of the milk, but also upon the 
child. When the mother is at an advanced age, especially if she is a 
primipara, wet-nursing is of itself forbidden, by the want of milk; at 
any rate, it is in all cases to be dissuaded from on account of the thin- 
ness or poverty of the milk. Acute diseases, exanthema, typhus, 
puerperal fever, etc., usually cause stoppage of the milk; as long, how- 
ever, as it is secreted, the child should not be weaned. Such milk 
does not act injuriously upon the child, and its abstraction is, in all 
instances, very advantageous to the mother. 

When none of these evil conditions exist, it should be made every 
mother's sacred duty to suckle her own child. Frail constitution and 
smallness of stature cannot remove this obligation ; otherwise most of 
our city women would be exempt from it. Aside from all other cir- 
cumstances, the milk of its own mother always agrees best with the 
child, for it is an often-observed fact that the child of a feeble mother 
will prosper at the maternal breast and grow excellently, while a 
strange child, whose guardians had been misled by the good appear- 
ance of the first, which had been given this feeble mother for a wet- 
nurse, would thrive under no circumstances. 

If a mother cannot or will not suckle her own child, then a wet- 
nurse is always the best substitute. 

It is very difficult to prescribe general rules for the selection of a 
wet-nurse, because a number of local circumstances come into consid- 
eration here, which must, naturally, difi'er in different cities and coun- 
tries. 

If the selection can be made from a number of women, who ofi'er 



NURSING AND CARE OF CHILDREN. 31 

themselves for the situation of a wet-nurse, that one should always 
receive the preference which has given birth to, and at her own breast 
brought up, a robust, healthy child. If this can be confirmed by per- 
sonal or creditable evidence, we have the greatest guarantee that after 
the expected deliveries the nursing will proceed "vvith equal regularity. 
It is always well to procure a wet-nurse who has been confined three 
or four weeks before the woman whose child she is to suckle, for in the 
first three weeks almost every parturient woman has a tolerable quan- 
tity of milk to display ; but, in many, the milk, after this period, de- 
creases from day to day, and thus, in case it is necessary to engage a 
wet-nurse who has only been confined a few days before, we may be 
compelled, in a few weeks, to discharge this expensive individual, on 
account of insufficient milk. Moreover, the sequelae of parturition, and 
particularly those annoying and tedious abrasions of the nipples are no 
more to be apprehended in a woman who has already nursed several 
weeks. The advantages enumerated here, at any rate, outweigh the 
slight disadvantage that the milk of such a wet-nurse, by rights, belongs 
to a child that is several weeks old. On the whole, the chemical com- 
position of the milk in one and the same wet-nurse, and still more in 
diff'erent ones, is so changeable that it is merely a fortunate coin- 
cidence when the milk of a strange woman agrees as well with a child 
as that of its own mother. 

The best age for a wet-nurse is between twenty and thirty years ; 
still, many exceptions may be made to this rule ; girls under twenty 
years are mostly primiparas, and therefore as yet do not possess the 
necessary qualifications for wet-nurses. In persons who are more 
than thirty years of age, the metamorphosis of materials no longer 
takes place with sufficient activity, such as is requisite to produce 
milk that is satisfactory in qualit}^ and quantity. The French physi- 
cians maintain that brunettes have a more nutritious milk than the 
blondes, of which, in Germany, I have not yet been able to convince 
myself. As regards the mammary glands, it is necessary that they 
should be of moderate size, should be covered with healthy integu- 
ment; the nipples should be two or three lines prominent, and on 
pressure of the mammee the milk should flow from the lacteal ducts 
in numerous fine streams. Formerly it was also insisted upon that tlie 
wet-nm-se should have good teeth ; but this, on account of caries of the 
teeth having become so general, now seems to be entirely neglected. 
It seems to me much more important, however, that she should have 
healthy, firm, red gums. Pale, bluish, easily-bleeding or foul-smelling 
gums always give rise to a suspicion of poverty of the blood, or diffi- 
cult digestion, two conditions which in no way harmonize with wet- 
nursing. Among our people, the phlegmatic and submissive wet- 



32 DISEASES OF CHILDREN. 

nurses are the most desirable ; an imperious person can never serve as 
a wet-nurse in a house where several servants are employed ; for she is 
barely engaged before she makes them feel her unbearableness, and 
after several days seeks to drive them from the house. The finale of 
the whole scene is, that the peace-disturber is discharged, and the 
family physician, who is expected to have an expedient for every thing, 
has to procure another wet-nurse. Generally, country girls are pre- 
ferred to those from the city. If it were true that the morahty in the 
country is greater than in the city, then this would no doubt be an 
important reason; my experience, however, does not confirm these 
suppositions. In most country wet-nurses the additional evils often 
exist that they become seriously home-sick, cannot tolerate the city 
board and manner of living, and with difficulty become acclimatized, 
so that, notwithstanding their stronger formation and their more 
developed breasts, they render less service than a factory-girl or a 
city servant-maid. 

Before a wet-nurse is engaged she and her child must submit them- 
selves to an examination of their entire bodies ; the child must be well 
nourished, should be sufficiently fat for its age, and on no parts of its 
body should have the least suspicious-looking sore. The nurse should 
have the above-described qualifications of the breasts and gums ; the 
physical examination of the thoracic cavity should reveal no abnormi- 
ties ; she should be free from all kinds of ulcers, and the mouth, anus, 
and genitals, in particular, should be carefully examined for traces of 
syphiKs. 

All these precepts only find their apphcabihty when a selection 
can be made from several wet-nurses. When, however, as is frequent- 
ly the case in small places, a person must be content when he is able 
to find one in the whole vicinity that oflers herself for that situation, 
any one may then be taken that is free from febrile diseases and 
syphilis, and suffers from no demonstrable tuberculosis, secretes a suf- 
ficient quantity of milk, and has healthy nipples. 

We now come to the important point, i. e., the milk and its chemi- 
cal and microscopical qualifications. 

The specific gravity of human milk averages 1.032. If it is allowed 
to stand quietly for some time, a thick, rich in fat, yellowish-white 
stratum, the so-called cream, will form on its upper surface, while the 
fluid found beneath it, poorer in fat and therefore specifically heavi- 
er, has a bluish-white color. Fresh woman's milk is bluish white or 
pure white, has a feebly sweetish taste and alkaline reaction ; but, 
when it is allowed to stand m a temperature not too low, it grad- 



NURSING AND CARE OF CHILDREN. S3 

iially becomes neutral^ and finally reacts acid and forms in small 
lumps. 

The essential difference between woman's milk and cow's milk does 
not consist in the differences of the quantities of the milk-sugar and of 
the butter, but in this : that the casein of cow's milJc^ when it turns 
sour, curdles into large lumps, and even into a solid gelatinous 
mass y whereas the casein of woman'' s milh always coagulates hito 
small lumps and loose flaJces. 

In the microscopic examination, fresh human milk presents itself as 
a clear liquid, in which, as in an emulsion, fat globules, which have been 
called milk-globules, are suspended. Milk-globules vary in size, most of 
them having a diameter of 0.0012 — 0.0020'", but if the milk is agitated 
a little, allowed to stand for several hours and then examined from the 
upper layer, along with the ordinary milk-globules, many large oil- 
globules will be found, the diameters of which increase to 0.03 or 0.04'". 
(See PI. IT., Fig. 3.) 

By the microscope alone, without the aid of chemical reagents, it 
is not possible for one to convince himself that the milk-globules have 
proper enveloping membranes. However, the presence of an envelop- 
ing membrane may be easily demonstrated, and, in fact, in two different 
ways. The one method, that of Henle, consists in the application of 
diluted acetic acid, and observing the acidulated milk under the 
microscope. The milk-globules in consequence undergo such an al- 
teration, that, if they were only minute oil-drops, they would never 
be capable of manifesting. They become very much distorted, some 
caudated, others biscuit-shaped ; on most, however, a minute drop be- 
comes visible, which appears almost like a granule of the milk-globule ; 
to this minute drop new ones become added on some places, so that 
around the now diminished milk-globule an entire circle of fine drops 
occasionally forms. By the application of concentrated acetic acid, the 
milk-globules fuse together into large drops. The second method is 
that of E. Mitscherlich, and consists in this : when fresh milk is agitated 
with ether, the milk remains unaltered, and the ether takes up only 
a small quantity of the fat. Were the milk a simple emulsion, it would 
surrender all its oil to the ether, and would itself be converted into a 
transparent, or at least a semitransparent liquid ; if some substance is 
now added which possesses the power of dissolving the enveloping 
membrane, for example, caustic potash, or carbonate of the same, the 
ether then takes up all the oil, and an almost transparent liquid whey 
remains behind. 

Besides the milk-globules, other elementary substances occur in the 
milk, namely, colostrum-corpuscles or corps granuleux of the French. 
Physiologically they are only found in the first few weeks alter the 
3 



34: DISEASES OF CHILDREN. 

delivery ; they then diminish rapidly, and always reappear as soon as 
any sickness supervenes upon the confinement, or the nursing-woman 
is attacked by an acute febrile affection. They consist of irregular, 
conglomerated, very small oil-globules, held together by an amorphous, 
slightly-granular substance, and, according to Henle^ are of 0.006'" to 
0.023'" in diameter. Ether dissolves these much more readily than 
those of the milk-globules ; acetic acid and caustic potash dissolve the 
granular intermediate substance, and disperse the oil-globules ; iodine- 
water dyes the colostrum-corpuscles intensely yellow. There is, there- 
fore, no doubt of these corpuscles being very small oil-globules em- 
bedded in an albuminous substance ; a granule and an enveloping 
membrane cannot be demonstrated. (See PI. II., Fig. 4.) 

Along with these principal elementary substances of the milk, some 
solitary epithelium-cells and mucous corpuscles are also found in it ; they 
only occur in larger quantities in local affections of the mammary gland. 

Coaguldble fihrine occurs only in milk containing blood. 

Blood-corpuscles are seldom found in the milk, and ordinarily min- 
gle with it only when erosions of the nipples exist. Fungi and infu- 
soria are never found in fresh human milk. 

As regards the chemical composition we have here : (1), sugar of 
milk (0^2-^12012)5 which in human milk is found from 3.2 to 6.2 per cent. 
Colostrum contains most of the milk-sugar (7 per cent.) ; its quantity, 
according to Simon'' s investigations, diminishes from month to month ; 
it seldom, however, falls below 4- per cent. 

(2.) Fat, Butter. — Butter forms the contents of the milk-globules, 
and may be tolerably well isolated by destroying the enveloping mem- 
brane (by churning). The individual fats of woman's milk have not 
yet been subjected to accurate analysis, but this much is known — 
that they very quickly become rancid and form volatile oleic acids. 
The amount of fat in human milk is not constant. Simon found from 
2.53 up to 3.88 per cent, of butter ; Clemon and Scherer on the fourth 
day after the delivery found 4.3 per cent., on the ninth 3.5 per cent., 
and on the twelfth 3.3 per cent. ; Chevalier and Henry 3.5 per cent. 
In the colostrum Simon found 5.0 i^er cent, of butter. It is a remark- 
able fact that, by milking or artificial sucking, the milk that exudes 
last always contains more fat than that which has flowed out first, 
the other elements remaining unaltered. As this observation was first 
made in cows, it was supposed that the milk commenced to separate 
itself already in the fodder, so that the w^atery portion was greatest 
in the teats and less in quantity higher up ; but, as JReiset also observed 
the same phenomenon in woman's milk, which at various intervals was 
extracted from the breast of a wet-nurse, the reason has therefore to 
be sought in some other cause than in the presumed mechanical cir- 



NURSING AND CARE OF CHILDREN. 35 

cumstance, since simple explanation of dependence by virtue of the 
position of the breasts cannot be entertained. 

According to my latest researches, the quantit}^ of fat in woman's 
milk varies extraordinarily. I have succeeded in producing an ex- 
tremely simple optical milk-test, with which an accurate estimation of 
the amount of cream can be made in two or three minutes, and indeed 
with a very small quantity of milk. A detailed description of the in- 
strument and the applications that have hitherto been made of it, is 
to be found in an appropriate brochure^ " A New Milk Test," F. Encke, 
1862. In this manner the quantity of fat can be surely ascertained, 
and, what is of still more importance, with merely a couple of cubic 
centimeters of milk. The method hitherto employed for ascertaining 
the quantity of fat in human milk consisted in filling a galactometer, 
graduated by a scale of one hundred lines, with the milk pumped out 
from the breast, up to the line, allowing it to stand quietly for twenty- 
four hours, and then to read off the thickness of the stratum of cream. 
Good woman's milk must show no less than three lines thickness of 
cream. This galactometer, however, has the disadvantages that the 
investigation can only be completed after twenty-four hours, and that 
it is often difficult and painful to pump out so large a quantity of milk 
from a wet-nurse's breast. With my optical milk-test both of these 
disadvantages are avoided. 

Sugar of milk and butter contain no nitrogen, and are the so-called 
respiratory material of woman's milk. 

(3.) Casein is found liquid in woman's milk, so long as it does not 
react acid ; it becomes separated into light flakes as soon as a super- 
abundant amount of lactic acid has formed through the decomposition 
of the milk-sugar. The milk of a good wet-nurse should contain 3 to 
3.5 i^er cent, casein ; the colostrum, however, contains a little more, 
nearly 4 per cent. It is very difficult and requires a long time to ascer- 
tain the chemical quantity of the casein, and therefore it may be ap- 
propriately omitted in the selection of a wet-nurse. Casein is the only 
nitrogenous substance found in the milk. 

(4.) The soluble salts of human milk are chloride of sodium, chlo- 
rate of potassa, and alkaline phosphates, and in addition to these 
also potassium and sodium, which are found combined with the 
casein. 

The insoluble salts are the phosphates of lime and of magnesia, 
which especially belong to the casein, and traces of oxide of iron and 
of fluor. 0.16 to 0.25 per cent, of salts, on an average, are found in 
human milk; 0.04 to 0.09 per cent, of which are soluble. The quan- 
tity of salts in the colostrum is greater than in woman's milk at a later 
stao'e of lactation. 



36 DISEASES OF CHILDREN. 

Vernois and JBecquerel examined the milk of eighty-nine nursing- 
women, and furnish us with the following average numbers : 

Density 1032 

1,000 parts of milk contain : 

Water 889.08 

Sugar 43.64 

Casein 39.24 

Butter 26.66 

Salts ■ 1.38 

There are certain circumstances which possess a marked influence 
over the synthesis of the physiological milk, namely : 1, innervation ; 
2, the time that has elapsed since the confinement; 3, the manner of 
dieting the wet-nurse ; and 4, the sexual functions. 

(1.) Innervation. — Tlie injurious influence which anger, fright, 
pain, nervous attacks, etc., are apt to exercise upon the milk, has 
been long known. The chemical changes which take place here have 
been less accurately investigated. In this respect the mammary gland 
resembles the lachrjTual gland, which participates in almost every 
mental excitement. It is a fact that those children who drink at the 
breast of a wet-nurse who is mentally excited, soon after begin to cry 
violently, suffer fi'om colic, get diarrhoea, and are sometimes attacked 
by convulsions. Whether the milk can thereby become so poisonous 
that children after partaking of it will die, must be doubted. When 
we bear in mind that a disproj^ortionately large number of children, on 
the one hand, in general die suddenly, and, on the other hand, that 
there are nurses who almost daily become angry, we would therefore be 
more inclined to beheve in an accidental concomitance than in an actual 
poisonous milk. I once had an hysterical woman under treatment, who 
suckled her child, and was not a little surprised, when, after one of her 
hysterical attacks, I pumped out a couple of teaspoonfuls of milk from 
her breasts, to find this milk almost totalty transparent, hke whey, and 
devoid of all saccharine taste. For the whole of that day she did not 
allow the child to drink at her breasts ; and, 'twenty-four hom^s after, 
the usual, very thick, yellowish- white milk, rich in fat, was again 
present, on which the child throve amazingly. It is also well known 
that cows give much less milk than usual when they are milked by 
strange persons. It is even said that they sometimes will give no milk 
at all when they are irritated during the milking, or annoyed by the 
presence of strangers. This must be due to a sudden diminution of 
the secretion and partial reabsorption of the secreted milk ; for the 
milk cannot be voluntarily retained, since no muscular apparatus an- 
sweriQg to that purpose exists. At any rate, it is e\"iGent enough 
from these statements that great attention must be bestowed upon 



NURSING AND CARE OF CHILDREN. 37 

the psycliical disposition of the wet-nurse, and that there are perfectly 
healthy, well-developed women who, nevertheless, are totally useless 
as wet-nurses. 

(2.) The time that has elapsed since the confinement has a great 
influence upon the composition of the milk. The colostrum, or the 
first milk, in addition to the already-mentioned chemical bodies, con- 
tains also albumen, mucus, and large granular colostrum-corpuscles. 
The size of the milk-globules is still more unequal than is the case 
later on. Butter and salts are found in larger quantities than at a 
later period, and to this is due the slightly laxative effect of the colos- 
trum. The milk-sugar decreases in quantity from month to month, 
and finally remains at 4 pr. c. as a minimum. 

(3.) The articles of food of the %oet-nurse^ ^n^qts. they are insuffi- 
cient, materially diminish the quantity of the milk in general, and the 
soKd component parts in particular, so that a hungering wet-nurse 
supplies but little and watery milk of a light specific gravity. But- 
ter and casein diminish in the highest degree. 

Vemois and Secquerel have made numerous experiments in this 
direction, and found the following numerical differences : 

In good nutrition. In average nutrition. 

Specific gravity 1,034.68 1,031.91 

Water 883.86 891.80 

Solid component parts 111.14 108.20 

Sugar 42.97 43.88 

Butter 26.88 25.92 

Casein 39.96 36.88 

Salts 1.33 1.52 

It is difficult to decide whether individual articles of food make 
more milk than others, and, in this respect, no general rules can be 
established, because the assimilation of the various articles of food 
varies extremely in different individuals. This much, however, is 
certain, that the quality and quantity of the milk are not in exact 
relation to the amount of nitrogen contained in the food. A wet- 
nurse from the country, for instance, will give more and better milk 
when fed upon the coarsest meal and milk-diet than if she consumed 
the largest piece of roast-beef every day. The use of alcohol or 
alcoholic drinks imparts to the milk a stupefying qualification. Tlie 
nurslings sleep much, are soon affected with cerebral irritation, digest 
badly, and become emaciated. In countries where beer is a popular 
drink, the women consider it impossible for them to suckle without 
consuming two or three mugs of beer daily. Those that were ha- 
bituated to large quantities of beer in the unimpregnated condi- 
tion, may continue to partake of it during lactation ; they will produce 



38 DISEASES OF CHILDREis'. 

by it no injurious effects upon themselves nor upon the child. But 
when wet-nurses first learn to drink beer during lactation, and strive 
now with ah their powers to consume a large quantity of it at one 
time, marked cerebral congestion and digestive disturbances are in- 
duced thereby, which, at any rate, have injurious effects upon the 
nursling. 

Many remedies, which have been administered hy the mouth, 
were subsequently detected in the milk. Most of the salts soluble in 
water, if they have not produced a profuse diarrhoea, are found in the 
milk again ; iodide of potassium may be most easily and decisively de- 
monstrated. The milk is agitated with a little starch-flour, and a few 
drops of nitric acid are added to the mixture, when the starch will 
instantly become converted into the weU-kno^vn dark-brown iodine 
paste. Various coloring substances also pass over into the milk. In 
the milk of cows, fed with esparsette, a blue coloring matter forms, 
which is said to possess analogous properties to indigo. 

Absinthium (wermuth) makes the milk bitter, the ethereal oils of 
garlic and of the thymio3 taint it with the odor of these vegetables. 
When a drastic purgative of any kind is administered to the wet- 
nurse, its effects, in most cases, will become apparent in the milk, 
and, through it, upon the child. The treatment of the nursling, by 
remedies administered to the mother, is, on the w^hole, a useless tor- 
ture to the latter ; when similar remedies are actually indicated, the 
child will surely be found to tolerate them just as well when they 
are administered to it in properly-divided doses directly from the 
medicine-glass, as when they have first been taken up by the circula- 
tion of the mother, and then secreted by the mammary glands in very 
small and certainly in not accurately definable quantities. 

(4.) TJie sexual functions have an undoubted influence upon the 
secretion of the milk. If the wet-nurse menstruates, her milk in 
general will be sparsely secreted, but its solid component parts do 
not decrease in quantity ; on the contrary, they become augmented. 
Butter and casein increase decidedly, milk-sugar and the salts demon- 
strably. The child thereby becomes somewhat restless, and displays 
the signs of disturbed digestion. But, after the termination of the 
menstruation, the former composition and quantity of the milk return, 
and for this reason it does not seem proper to immediately discharge a 
menstruating wet-nurse, as is so very frequently done ; it is much more 
advisable to wait for the recurrence of the catamenia, and then only 
to discharge the nurse when the child remains indisposed for some 
time after the menstruation, and does not thrive in the same manner 
as before. 

If pregnancy recurs, the continuance of lactation is of itself pro- 



KURSING AND CARE OF CHILDREN. 39 

hibited, because the secretion of the milk immediately becomes very 
much diminished, and the milk again assumes the properties of colos- 
trum. If, in exceptional cases, these changes do not take place, the 
nursling must nevertheless be weaned, because, otherwise, the growth 
of the foetus will be interfered with in the highest degree. Whether 
a coitus, upon which no gestation follows, is in itself injurious, I am 
unable to say ; it does not seem possible, however. 

Rapidly-recurring pregnancies exercise an injurious influence upon 
the secretion of the milk. On account of the anaemic and general hy- 
perassthesia of the women which originates therefrom, but little and 
insufficiently-nourishing milk is generated. 

The milk, through certain diseases, undergoes important changes. 
Generally, in the milk of wet-nurses sujEFering from febrile affections, 
larger quantities of colostrum-corpuscles are found. Its quantity 
thereby decreases vastly in amount, or it dries up altogether. The 
solid component parts, however, do not disappear with equal rapidity 
with the watery, so that, at the invasion of a febrile disease, a milk, very 
rich in solids, is generated, and for that reason indigestions are very 
easily induced in the nursling. In general, the rule may be established, 
that the nursling should be left at the breast of the wet-nurse so long 
as she has milk, and the child suffers no very great digestive disturb- 
ances ; it is, however, necessary to premise that the disease must be 
not of a contagious character — nor an acute exanthema, nor petechial 
typhus, nor syphihtic affection. 

For the practical physician, it is entirely sufficient to prove the fol- 
lowing properties of the milk : (1.) He fills his graduated galactometer 
with milk, and allows it to stand quietly covered for twenty-four hours, 
at the expiration of which time the stratum of cream should comprise 
at least three lines of the glass in thickness. (2.) He tests the milk 
Avith blue htmus and yellow turmeric paper. The litmus-paper should 
in no case become red ; the turmeric-paper should turn slightly brown. 
(3.) He puts a few drops of the fresh milk upon the tongue. It should 
have an insipid and slightly-sweetish taste. (4.) He puts one drop 
of the milk under the microscope. If the wet-nurse has been con- 
fined for more than eight days previously, the colostrum-corpuscles 
and epithehum-cells should not be present at all, or only in very small 
numbers. The milk-globules ought not to be of too unequal sizes, nor 
be present in large quantities. 

In general, it may be remarked that the state of health of the wet- 
nurse, her digestion, her sleep, her respiration, her skin, and her geni- 
tals, deserve a much greater attention than the chemical and morpho- 
logical composition of the milk, and that it is more important for the 
physician to satisfy himself accurately of a sufficient quantity of milk 



40 . DISEASES OF CHILDRE^". 

than to prove fhe qualitative projDortions. The quantity of a milk- 
secretion may be ascertained by weighing the child both before and 
after nursing, by which it should always be found to have increased 
from three to five ounces. But, as these weighings are troublesome, 
and not very much liked in private practice, simj^ly watching the child 
while it nurses will serve to inform us whether the nurse has sufficient 
milk or not. If the child does not exert itself very much at it ; if the 
milk runs out at the angles of the mouth ; and if, after half an hour, 
it quietly and contentedly forsakes the breast, one may be convinced 
that it has obtained a sufficient quantity of milk. 

If, now, one has had the rare luck to find a wet-nurse answering in 
every respect, the following precautions are to be taken to preserve 
her future good health. Warm baths are, for persons from the lower 
ranks of society, something so rare and unusual, that it does not seem 
advisable to allow the wet-nurse to take whole baths at once; it is 
best to have her take several parts of baths in the week ; warm water, 
with soap and good-will, will accomphsh a tolerable degTee of clean- 
liness. If the wet-nurse has been used to warm-water baths before, 
they will also be harmless to her during lactation. The same holds 
good with river and cold sea baths. The rule should always be 
adhered to, not to alter the habits and manner of li\TQg of the wet- 
nurse, if it is only possible to carry them out in conjunction with a sen- 
sible house regime. The wet-nurse may partake of every tiling^ with 
the exception of highly-spiced and very salty food and alcoholic drinks, 
that is palatable to her ; and it is always best, if her manner of living, 
a couple of between-meals excepted, does not deviate from those of 
the family in which she has come to live. All her dishes must be 
well prepared and suitable to her taste ; for the rest, it is really super- 
fluous to ordain a detailed bill-of-fare. 

Her sleeping-room should be well ventilated, and she herself must, 
without regard to the weather, take daily exercise in the fresh air ; it 
is only necessary to observe here, that, if she is not well and long 
known, she should never be allowed to go out alone. 

A great prejudice exists in the public mind against menstruating 
wet-nurses, and a few spots of blood upon their linen suffice to 
cause the parents of the nursling the greatest anxiety. The dan- 
ger, however, is not so great by far as it appears ; most wet-nurses 
menstruate but feebly and irregularly, and although during the cata- 
menial flow they have usually somewhat less milk, and although the 
children at this time, it is true, may be seized with colic pains, yet, in 
from one to three days, the whole process is over, and wet-nurse and 
nursling again enjoy the best of health. 

Two principles must be maintained and daily inculcated : 



NURSING AND CARE OF CHILDREN. 4.^ 

(1.) The breast is no quieting remedy for the crying child, but it 
is only to be given to it regularly every two or three hours. Any 
restlessness that occurs during these intervals is no sign that the child 
is hungry, but will be found to be due to some other cause ; frequently 
to tight dressing, wet diapers, or the like. In the night a four hours' 
pause, for instance, from nine in the evening to one in the morning, 
suffices completely to allow the wet-nurse to enjoy the first half of the 
night's rest. The advice of some Pasdiatricars, not to put the child 
to the nurse's breast from evening till morning, I have not yet been 
able to carry out. 

(2.) The wet-nurse should never be allowed to keep the child with 
her in bed. I am convinced that many of the mysterious sudden deaths 
of nurshngs are to be explained by suffocation in the bed of the 
mother or wet-nurse. The nurses fall asleep wliile suckling the child, 
and either suffocate it by themselves or by the bedclothes falling 
upon it. A cautious mother should, therefore, never begrudge her- 
self the trouble to look after the wet-nurse several times a night 
and insist with the utmost firmness upon the latter's carrying out 
this rule. 

. Many wet-nurses suffer from obstinate constipation, and, by hiding 
the evil, ultimately bring upon themselves actual digestive disturb- 
ances. They should therefore be instructed not to neglect it, but 
immediately to inform the parents of the child of it ; the cure is very 
simple, for the entire trouble may be removed by a few drachms of 
conf. sennae or boiled prunes. 

The wet-nurse ought to be treated with sympathy, and in a friendly 
manner ; the poor creatures are heartily to be pitied, notwithstanding 
their high wages, who, by their own fault, it is true, get so far as to 
give away their own child, and in its place take a stranger's to their 
breast ; such a service, if regarded in its true light, cannot be paid 
with money. 

Finally, the question arises. When and how should the child be 
weaned ? 

The answer for this question but rarely depends upon the opinion 
of the physician alone ; usually a number of external causes, or regard 
for the health of the wet-nurse or of the child, influence the determi- 
nation of the period for weaning. Here, too, as unfortunately in so 
many other things in the practice of medicine, the affair cannot be 
disposed of with a few numbers / many circumstances must be placed 
opposite each other, and carefully weighed. The most natural is mani- 
fest, to allow the child to nurse so long as it readily takes the breast, 
thrives upon it, and the wet-nurse does not suffer therefrom the 
least prejudicial effects in her health, such as weakness, pallor, emaci- 



42 DISEASES or CHILDREN. 

ation, hyperaesthesia, etc. This condition in a healthy nurse and a 
strong child lasts, in our climate, on an average, from four to eight 
months. Then the nurse perceives that the secretion of milk does not 
increase in comparison to the increasing growth of the appetite of the 
child, and consequently the nursling does not obtain sufficient nutri- 
ment. Now the period has arrived when the child may be allowed 
other nutriments besides the breast. Here, too, it is difficult to say 
w^hether this or that article of food is the most appropriate, and 
the rest injurious, for all children have not the same power of digestion 
and the same taste ; some, for instance, will take no cow's milk, nor any 
thing prepared with it, so long as they get the breast, if it is only once 
a day, while they will take the various beef-broths without much objec- 
tion ; others will take no meal-porridge, but only cracker-soup ; while 
still others will partake of no kind of milk preparations, but only of 
beef-broths, etc., etc. I therefore cause the commencement to be made 
with a thin fresh bread-and-milk preparation ; if in eight days this 
does not succeed, I try meal-porridge ; and if this is also unacceptable, 
then I resort to thin beef-broth and bread. Some one of these three 
preparations will be tolerated by every child if the breast of the wet- 
nurse is incapable of supplying sufficient nutriment. For four weeks 
the child gets one mess a day ; for four weeks more, two ; and for 
four weeks more, three times daily. In the mean time the child has 
learned to masticate the crust of white bread and to drink water, 
takes the breast but once during the night, and does not miss it 
very much when finally at night it gets lukewarm cow's milk in its 
stead. 

This is the surest and safest method of weaning a child. Often 
enough it has to lose the wet-nurse at once, or in a very short time. 
In that case it is especially important to take into consideration the 
dentition periods. If the child has happily just passed through a 
dentition period, so that it may be assumed with certainty that it 
will be free from the troubles of dentition during the coming weeks, 
then, in most cases, it will also bear the sudden weaning without any 
danger ; but, on the other hand, a profuse diarrhoea comes on in most 
cases, which often cannot be arrested, or from the effects of which, 
at least, children suffer for months. As soon as a child has cut its 
upper and lower incisor teeth. Nature has assigned to it more solid 
food than the milk of its mother. At any rate, it is useless, and, for 
most mothers injurious, to suckle their children beyond the first year. 
In most instances they then w^ean themselves, because they do not 
obtain a sufficient quantity of milk from the breast at one time. I 
once treated an American lady, who still suckled her son who was 
tioo and a half years old, tiU one morning, when the strongly-devel- 



XUKSING AND CARE OF CHILDREN. 43 

oped, robust cliild was called to be nursed, he very kindly replied : 
" I thank you, dear mamma, the nursing is too tedious for me ! " 

If the mother herself is unable to suckle, and has not the means 
wherewith to hire a wet-nurse, there is no other alternative than to 
try artificial feeding. 

The following conditions are requisite for an artificial rearing. 
Care in the selection and preparation of the nutriments, great pa- 
tience and perseverance, the strictest accuracy, manual dexterity, and 
the highest degree of cleanliness. 

The best substitute for Avoman's milk is cow's milk, not because it 
resembles it most in composition, but because it can be obtained 
most regularly and easily at a low price. Those only who have de- ' 
voted some time to the quantitative examination of milk will be able 
to agree with me that the few per cents, more of casein and butter, 
and the few per cents, less of milk-sugar alone, cannot make the 
great difference which certainly exists between the nourishing of a 
child with woman's milk and cow's milk. Indeed, the secretion of 
the mammary glands, like that of the kidneys, has tolerably wide 
physiological boundaries, out of which some really fine medium num- 
bers may be constructed. But, nevertheless, it does not follow from 
these averages that that milk is the best which stands nearest to the 
physiological average. 

The important difference between woman's and cow's milk is, as 
already observed above, to be found in this, that the casein of woman's 
milk curdles in the stomach into small light flakes, forming a very 
loose jelly, while that of cow's milk coagulates into large, compact 
lumps, of which one may convince himself by causing a child brought 
up at the breast, and one artificially reared, to vomit a quarter or half 
an hour after the meal. This is easily accomplished by rapidly 
mo\dng the child about, by frictions over its gastric region, etc. The 
loose flakes of the woman's mUk are easily digested and assimilated ; 
the firm lumps of casein of the cow's milk, the infantile gastric juice 
is incapable of dissolving, they are thrown up again or wander 
through the whole intestinal canal as large, sour, undigested masses, 
irritating it in its entire length. Hence it all depends upon our 
ability of depriving the casein of cow's milk of this property, and that 
in a great measure may be accomplished by rendering it slightly 
more alkaline. For this purpose I have been in the habit of using 
for some time back a solution of carbonate of soda ( 3 j to water 
3vj), a teaspoonful of which is added to the milk at every meal. 
^Vhen the milk is boiled into a mess or porridge, I cause the solution 
to be added to the cold milk, and in summer the entire quantity of 
milk to be consumed in the twenty-four hours should be rendered 



44r DISEASES OF CHILDREX. 

alkaline immediately upon its arrival at the house, by adding a table- 
spoonful of the solution to every five ounces of milk. For very young 
children I cause, in addition, one-third of water and as much milk- 
sugar as can be taken upon the point of a knife to be added at every 
meal ; children over three months old drink cow's milk as it is, but 
always with the addition of the carbonate. I have seen dozens of 
children brought up upon milk thus prepared, and the majority have 
experienced no digestive derangements whatever. If the parents are 
sensible, they will abstain from giving the child all other kinds of food 
but this milk for the first three months, and at the beginning of 
the fourth month one other mess a day only may be allowed. The milk 
should be boiled immediately upon its arrival at the house, because 
the curdling is thereby delayed for some time. The best mess is pre- 
pared by soaking about an ounce of stale wheat bread for fifteen min- 
utes in some cold water, when the water will be found to be slightly 
acid ; the bread is then boiled into a uniform broth with six to eight 
ounces of alkaline milk, to which as much milk-sugar is added as can 
be taken upon the point of a knife. Meal-porridge is much preferred 
to this preparation, especially among the lower classes, for upon this, 
too, a gTeat number of children thrive excellently well, and it is yet 
a question whether this preparation is not as harmless as the bread- 
jam. When four-fifths of the children brought up by hand get meal- 
porridge, and only one-fifth bread-mess, then, in assumed equal digesti- 
bility of both nutriments, four children fed upon meal porridge ought 
to suffer from indigestion before one child fed upon the bread-mess 
finally becomes sick. 

Now, whoever is not aware that actually four times as many chil- 
dren eat meal-porridge as eat bread-jam, very naturally must form the 
idea that the former is by far less favorably tolerated than the latter. 
But until detailed statistical tables, conducted for years, demonstrate 
this circumstance in clear indisputable numbers, no one can maintain 
that thin meal-porridge is more injurious than bread. In addition 
to the ordinary wheat-flour, rice-flour or arrow-root may also be em- 
ployed. The method of using arrow-root is as follows : A teaspoon- 
ful of arrow-root is put into a porcelain vessel, as much cold water is 
added to it as will make it a fine dough, a cupful of boiling milk (or 
also water, or beef-tea) is then added, the mixture is stirred a little and 
allowed to boil for a few minutes till the whole acquires the consist- 
ency of a fine light jelly. 

By far the most rational of all substitutes for the mother's milk is 
undoubtedly the so-called Lie'big''s soup, by which the great chemist 
has rendered an everlasting service to the Psediatrica. As is well 
known, we find : 



NURSING AND CARE OF CHILDREN. 45 

Blood-forming Caloric-geBerating 
material. material. 

In woman's milk 1 3.8 

" cow's milk, fresh 1 3.0 

" cow's milk, skimmed 1 2.5 

" wheat-flour 1 5.0 

A mixture of ^Ylleat-flour and cow's milk may therefore be easily 
produced that will jDresent the same proportions of blood-forming and 
caloric-generating component parts as human milk ; wheat-flour, how- 
ever, reacts acid, and contains much less alkali than woman's milk, less 
than is requisite for the formation of normal blood, and, finally, a 
totally unnecessary labor, the conversion of the starch-flour into 
sugar, is imposed upon the infantile organism. It is, therefore, desir- 
able first of all to convert the starch-flour to the soluble form of sus'ar 
and dextrine ; this is easily accomplished by the addition of malt-meal 
to the wheat-floiu-. When milk and wheat-flour are boiled into a thick 
soup, and malt-meal is added to this still hot soup, the mixture in a 
few minutes hecomes liquid and acquires a sweet taste j upon this 
and upon an addition of an alkali in order to neutralize the acid re- 
action of the wheat-flour is based the formation of JLiel)ig''s soup. 

The method prescribed by Liebig himself is as follows : " Half an 
ounce of wheat-flour, half an ounce of malt-meal, and seven and a half 
grains of bicarbonate of potassa, are weighed off; they are first mixed 
by themselves, then with the addition of one ounce of water, and 
lastly, of five ounces of milk ; the mixture is then heated upon a slow 
fire, constantly stirring it until it begins to get thick ; at this period 
the vessel is removed from the fire, and the mixture is stirred for five 
minutes, is again heated, and again removed when it gets thick, and, 
lastly, it is heated till it boils. The soup is purified from bran by pass- 
ing it through a fine sieve (piece of fine linen), and now it is ready for 
use. Barley-malt can be obtained at any brewery. First, it is sepa- 
rated from the impurities, and then ground in an ordinary coffee-mill to 
a coarse meal. Care should be taken to use the common, fresh wheat- 
flour, not the fmest^ because it is richer in starch-flour. Two parts 
of kali bicarb, crystal are dissolved in eleven parts of water, which 
will make a perfectly clear liquid. The troublesome weighing of 
the materials may be dispensed with, as a heaped tablespoonful of 
wheat-flour weighs pretty nearly half an ounce, a like tablespoonful 
of malt-meal, not quite so heaped, likewise weighs half an ounce, and 
an ordinary thimble filled with the solution of the bicarbonate contains 
nearly fifteen grains of the salt. Now, if in addition one ounce and 
five ounces of water are caused to be weighed off in a beaker-glass by 
the druggist, and the height of the fluids is marked by strips of paper 



46 DISEASES OF CHILDREN. 

pasted on tlie outside, then every thing is conveniently arranged for 
a sensible mother ; the bicarbonate of potassa cannot be replaced by 
the bicarbonate of soda, as important potassa salts enter into the con- 
formation of all our food, the milk and . blood-corpuscles. The soup 
thus prepared tastes tolerably sweet, and, when properly diluted with 
water, is tolerated even by nurslings. This soup, according to my o^vn 
experience and that of many German physicians, is the best substitute 
for the mother's milk, and has visibly saved the life of many totally- 
atrophied children. 

The greatest difficulty in large cities will always be the procuring 
of fresh, unadulterated milk. The milk obtained from general dealers 
is always far from being satisfactory, and it is absolutely necessary for 
one to be present at the milking and feeding of the cow, until he has 
become satisfactorily con\dnced of the honest dealings of his milk-pur- 
veyor. The milk used should always be from the same cow^, which 
should be allowed to roam in the free air several hours daily, and be 
fed almost vv^holly upon green fodder. 

If, on account of existing unfavorable circumstances, it is impossible 
to obtain such cow's milk for the child, other substances must be sub- 
stituted, the usefulness of which, however, when employed for a long 
time, is very ]3roblematical. Here belong veal-broth wdth yolk of eggs, 
gruels, salep, and carrot-broth. The latter has been very favorably 
spoken of, and is prepared in the following manner : One ounce of 
triturated yellow carrots is mixed with six to eight ounces of water 
and allowed to stand for twelve hours ; the mixture is then pressed 
out through a cloth. The juice is mixed with pulverized wheat bread 
(one part bread to four parts juice), and boiled for a few minutes over 
a slow fire, and finally is sweetened with a little sugar. There are 
childi^en who, under no circumstances, tolerate cow's milk. These can 
exist for months upon carrot-broth, mucilaginous or beef soups with 
yolk of eggs ; they grow, however, but very slowly, and never acquire 
a proper amount of flesh ; a trial must therefore be made with very 
fresh, sweet milk ; often the absorption and assimilation of the milk 
succeed later, though at first it was not tolerated at all. 

The manner in which the nutriments are to be administered to 
infants is not immaterial. They may be fed, from the very first day 
of life on, with a small spoon, or a cup having a snout, to which they 
readily habituate themselves, but it is better to use a sucking-bottle, 
because by this the facial muscles are exercised in an equal manner, 
as in children at the breast of the mother. 

The simplest form of sucking-glasses is a common bottle of four 
to five ounce capacity, with a tolerably narrow neck, upon the mouth 
of which several finely-cut bits of delicate sponge are secured by a 



NURSING AND CARE OF CHILDREN". 47 

piece of gauze. These s23onges should be changed several times 
daily, and are best preserved in pure cold water. When they are 
made to reach half an inch over the neck of the bottle, and if the 
gauze is made properly tense, they will imitate the form and con- 
sistence of the nipple. 

If these sponges are not good or elegant enough, the bottles 
may be provided with mouth-pieces of gold, silver, tin, or bone. 
Children drink very readily out of the perforated caoutchouc caps 
which lately have become so popular, and which are especially recom- 
mendable on account of their cleanliness. 

A very popular method of feeding infants is by the sugar-teat 
(Schnuller, Zulp). It is prepared by mixing pulverized sugar-crackers 
with milk or water so as to form a dough, which is then put into a linen 
rag and tied wdth a string so as to form a ball about the size of a 
small apple. This soft, sweet ball is put into the mouth of the child, 
when it cannot be quieted by the ordinary means, at which it instant- 
ly begins to suck, and thus may be kept quiet for hours. In general, 
nothing more can be said against cleanly-kept, often-renewed sugar- 
teats, than that the cheeks of the child, by the constant sucking, 
become enormously distended, and form disgusting protuberances 
when the mouth is closed without them. Usually, however, the 
contents of the rag, from its contact wdth the warm mouth, soon 
begin to ferment, the mucus of the mouth becomes acid, and directly 
upon that digestive disturbances supervene, and a fungous growth 
springs up upon the mucous membrane of the mouth, w^hich only 
too often leads to a sorrowful end. It is therefore the duty of every 
physician to prohibit the use of the sugar-teat whenever and wher- 
ever possible; but this, in fact, can be more easily advised than 
accomplished ; if we only think of the condition of a poor woman 
who all day long is plagued by a large number of small children, and 
at night, when she and the rest of the members of the family ab- 
solutely reciuire rest, the crying child wdll not leave her arm. She will 
then certainly say, " The physician gives good advice, not to use the 
sugar-teat; he, however, is not obliged to carry this crying child 
about all through the night ; " thus not one woman out of a hundred 
will withhold it from her child. 

From the lower classes it will hardly ever be possible to eradicate 
this fermenting ball, and among the better classes the child has a 
wet-nurse, or at least proper care, and the sugar-teat is renewed often 
enough, whereby it is generally rendered harmless. — So much for 
the nutrition of the first year of life. 

In the second year, the children may be allowed some soft, finely- 
cut meat. If they have no diarrhoea, nor are predisposed to it, they 



48 DISEASES OF CHILDREN. 

tolerate fresh ripe fruit excellently well ; on the other hand, boiled 
green vegetables and husk fruits very generally cause them indiges- 
tion. For a child two years of age, for example, I prescribe the 
following diet : Mornings, between six and seven o'clock in summer, or 
between seven and eight in winter, milk-gruel ; between nine and ten 
o'clock, a piece of wheat bread with very little butter on it ; twelve 
o'clock, well-prepared beef soup, meat with a little gravy, or potato- 
broth, or in place of the meat a meal-broth prepared with eggs, but 
with very little fat, green vegetables very rarely and in very small 
quantities; afternoon, between three and four, bread and milk, in 
summer, bread with fruit ; evening, at seven, beef-soup or milk-broth. 
Sugar, in general, agrees very badly with children, and it is highly im- 
portant for their digestion to habituate them to it as little as possible. 
After the children have passed the third year they tolerate all kinds of 
vegetables, and may, when otherwise well brought up, very appropriate- 
ly be allowed to eat at the table with the family ; it is only necessary 
to refuse them very salt, sour, and highly-spiced victuals, of all others 
they may partake in moderate quantities. Children should not be 
allowed to taste wine till they are fourteen years old, even beer is 
absolutely unnecessary, as likewise are tea and coffee. Home-made 
rye bread should be substituted for the ordinary wheat bread. It is 
well to cause children to eat the entire meal off one plate. They 
should consume all the soup allowed them before they can obtain any 
thing from the next dish. Aside from the labor saved by not repeat- 
edly changing the plates, children thereby acquire the good qualifica- 
tion of learning to eat every thing, and not to become lickerish. 

If we now take up the care of children, we encounter, first of all, 
the culture of the skin. The vernix caseosus of the foetus cannot be 
washed off with water, but must first be mixed with some kind of fat, 
butter, lard, or pure oil, and may then be readily wiped off mth a 
soft cloth. Infants should be bathed daily for ten minutes, in water 
of 92° F. Local affections do not suffice to counteract this rule ; but, in 
general febrile diseases, the bathing must be suspended. The stay in 
the water and the variations of the temperature, which in the undress- 
ing and in the rubbing of the children dry cannot be avoided, increase, 
as a rule, the heat of the skin and induce a higher degree of weak- 
ness. 

After the first incisors have cut through, the temperature of the 
water may be gradually reduced to 86° F. In the first year of life it 
is not advisable to employ cooler baths. In the second year, when 
the children have less frequent movements from their bowels, and they 
begin to get cleanly, it is no more necessary to bathe them every day, 



NURSIXG AXD CARE OF CHILDREN. 49 

three or four baths a ;v7eek, in water of 84° or 85° F., are sufficient. 
From the third 3'ear on, two or three baths weekly, in summer, daily 
river or sea baths, will keep the skin properly active. 

Children should be taught the art of swimming ; it is very useful 
and very invigorating to the health of both sexes. The culture of the 
skin not only requires cleanliness, but also the prevention of too great 
changes of its temperature, and this is accomplished by garments and 
warming. 

At the first dressing of the new-born, attention should be paid (1.) 
to the umbilical cord, that it is in no way dragged upon ; (2.) That the 
chest and abdomen are wrapped in such garments as will not hinder 
the respiratory acts that have but just been established ; and (3.) That 
the upper and lower extremities are allowed to assume their natural 
flexions. No child should be carried about upright, until it is itself 
able to raise its head and rotate it a little. The physician should be 
very cautious in advising that the child should be inured by the aid of 
Hght garments. It certainly cannot be denied that children inured in 
early life develop more rapidly and stronger, are seldom ill, and readily 
surmount a disease they may have acquired ; on the other hand, how- 
ever, it must also be admitted that many intestinal and pulmonary affec- 
tions of children have been induced by a too rapid change in the 
temperature or by insufficient covering of the breast and abdomen. 
When the anxious parents have at last been prevailed upon to resort 
to the inuring method, and the child subsequently falls sicks, the bit- 
terest reproaches, and not unjustly, will be heaped upon the physician. 
I therefore always resort to the expedient, never to disparage light 
garments wherever I meet with them, nor to absolutely insist upon 
them. Neither can unreasonable excesses of too warm or too cold 
garments be tolerated. When children learn to walk, they should 
have shoes with tolerably broad soles, which should be at least half an 
inch larger than the foot. Yain mothers begin at a very early period 
to direct their attention to the formation of a slender waist for their 
little daughters, which of course cannot be prevented in many cases ; 
for motherly vanity is a vexatious enemy to the rational physician. 

Finally, as regards the nursery-room, the child in the first eight 
days of its existence should be kept in a half-dark room, wliich is 
gradually allowed to become brighter, till finally, after fourteen days, 
the young eyes are perfectly accustomed to the light, and may be ex- 
posed to it without harm. From this time forth the nursery should 
be bright ; it should have at least two windows, the floor should be 
painted or covered mth oil-cloth, so that no water should permeate it, 
and the stove should only be used for heating the room and not for 
cooking-purposes. For the purpose of thoroughly ventilating the 
4 



50 DISEASES OF CHILDREX. 

room the windows should be kept open one half or one hour daily, 
during which time the child, of course, is to be removed to another 
room. Fresh air is undoubtedly an absolute necessity for a robust de- 
velopment. Children bom in summer should be taken out in the air 
from the second or third day on ; in winter, however, eight or ten weeks 
at least should be allowed to pass by before they can be carried out on 
a sunny noonday. Older children can never be out too much in the 
fresh air ; the earher they are sent out, and the later in the day they 
are called in, all the better do they develop. In cities, the physician 
therefore finds it necessary to insist with the utmost energy that fami- 
lies should hire themselves gardens or shady grass-plots, where chil- 
dren may remain undisturbed the entire day. The promenades in 
pubhc places, so much in favor -vvith the nursery-maids, cannot in any 
way replace the undisturbed enjoyment of the child in a private park. 



PART II. 

SPECIAL SUBJECTS 



CHAPTER I. 

DISEASES ORIGINATING DIRECTLY IN CONSEQUENCE OF DELIVERY. 

Although, in a discussion on the diseases of children, it appears 
perfectly conformable with the purpose to adopt the plan of the latest 
works on Special Pathology, to simply take up the diseases of one 
part of the body after another, and not to base the classification upon 
the nature of the pathological alterations, still in the " Paediatrica " 
we meet with a class of affections which have a definite physiological 
connection, and therefore must also be jointly treated of before all 
others. It is those diseases which are indebted for their origin to the 
act of the delivery, and to the transposition of the child from the 
uterus into the atmospheric air alone. Here belong : (A) Asphyxia 
of the new-born ; (B) Atelectasis of the lungs ; (0) Cephalaematoma 
of the new-bom ; (D) The pathological conditions of navel ; (E) Tris- 
mus neonatorum; (F) Sclerema; (G) Melaena; (H) Icterus of the 
new-bom, and (I) Ophthalmoblennorrhoea of the new-born. 

A.— ASPHYXIA NEONATORUM. 

Stk'COPE of the new-bom, or asphyxia (from a privativum and 
<y<^v^i-g, the pulse), is a condition in which the inspiratory muscles after 
the delivery do not contract at all, or only imperfectly, and the breathing 
therefore does not commence. The movements of the heart continue 
here tolerably rhythmical, although they are feeble and not always per- 
ceptible, and only heard on auscultation ; the name asphyxia does not, 
therefore, seem to have been very happily selected for this affection. 
Two different forms of asphyxia are distinguished in the new-born ; in 
the one form the children are cyanotic, usually they are very large 
and strongly developed, the integument is infiltrated, the tongue 



52 DISEASES OF CHILDREX. 

thick and blue, protruding from the mouth, the eyeballs project from 
their orbits, and the cardiac beats are feeble and unrhythmical. This 
form is also called asjDhyxia apoplectica, because it is probably due to a 
congestion of the brain, in consequence of imperfect action of the 
heart. In the other form the children are deathly pale, the extremi- 
ties hang down powerlessly, the lower maxilla drops down upon the 
sternum, the cardiac impulse and the pulsations of the umbilical cord 
are irregular and barely to be felt, the respiration is either totally ab- 
sent, or the thorax at short intervals rises short and spasmodically, 
and the meconium flows off involuntarily. The respirations constantly 
grow more infrequent, the cardiac beats feebler, and death usually 
ensues in a few hours. Between these two principal forms there are 
transitions which do not reflect perfectly either of the dehneations 
just sketched ; in general, however, they are rare. 

Etiology. — Asphyxia has various causes. It may originate from 
compression of the umbilical cord against the pelvic walls, or the cord 
is wound around the neck of the child, or the placenta has become 
prematurely detached. The skull may have suffered in its passage 
through the narrow pelvis or from the forceps, or the air-passages are 
plugged up with blood and mucus. Finally, early deliveries, feeble 
parents, and especially exhausting diseases of the pregnant mother, 
are known to be causes of asphyxia. Compression of the larger blood- 
vessels of the neck can only induce the apoplectic form, because a 
pressure that will merely make the arteries of the neck impermeable 
can scarcely produce asphyxia, as the more superficial cervical veins, 
with thin coats directly beneath, will only suffer. The flow of the blood 
to the head does not thereby become arrested, its return only is 
hindered. 

Compression of the navel-string, on the contrary, exercises an in- 
fluence over the umbilical vein before it does over the arteries ; more 
blood flows, therefore, from the foetus than to it, and anaemia with ex- 
haustion, and, finall}^, the so-called asphyxia nervosa, can only result 
from this condition. 

Patholog-ical anatomy does not here supply any constant results. 
At the autojosy, nothing but a still tolerably complete fetal circula- 
tion is found, and, in particularly violent deliveries, or very unfavor- 
able pelvic disproportions, extravasations of blood between the me- 
ninges or in the brain itself. 

The course of this evil, as may of itself be understood, must be a 
very rapid one ; if no regular respiratory acts and distinct cardiac beats 
take place in a few hours, life will cease altogether, which termination 
more frequently occurs in the nervous than in the apoplectic form. 
Very often, with proper assistance, the respirations are established 



DISEASES CONSEQUENT ON DELIVERY. 53 

after some time, the beats of tlie heart become stronger and more 
rhythmical, and the cyanosis in the one form, as well as the ab- 
normal pallor in the other, disappears completely. 

Therapeutics. — The treatment depends mostly upon the cause. 
First of all, the mouth should be thoroughly cleaned, and this is best ac- 
complished with the finger. By touching the .palate and epiglottis, 
shght acts of choking and coughing are induced, which alone may suf- 
fice for the establishment of the respirations. If nothing was achieved 
by the cleaning of the mouth, then, in the cyanotic form, two table- 
spoonfnls of blood should be allowed to flow from the severed funis. 
If the cord does not bleed any more, all further attempts at abstrac- 
tion of blood must be renounced. Pale children very naturally toler- 
ate no loss of blood, and are rather to be guarded against it by care- 
fully tying the cord. A very simple and always handy remedy is, a 
few slaps with the open hand upon the buttocks. Partly from the 
pain, partly from the shock, very useful reflex actions of the respiratory 
muscles ensue. If this procedure is also ineffectual, the child should 
be put in a warm bath, taken out in a few minutes, swung up and 
dovm several times, and then put into the bath again. A beneficial 
stimulation of the skin ensues from these alternate warmings and cool- 
ings of the child. Irritating fluids may also be dropped upon the chest, 
among which, vinegar, brandy, ether, and Cologne water, are the most 
useful remedies. A very much liked, often praised, and then again dis- 
carded procedure is the direct inflation of air. For this purpose, the 
mouth and nose having been first cleaned, the physician applies his own 
lips to the open mouth of the child and blows, when naturally the air 
will come out at the nostrils of the child ; if they are so permeable, the 
physician should compress them with his thumb and forefinger and 
then blow in air anew. It is a great error to suppose that any air is 
forced into the lungs by this method ; in most instances, the epiglottis, 
through the distention of the mouth with air, becomes depressed still 
more firmly upon the larynx, and then all communication between the 
mouth and lungs is completely cut ofi". Still, the irritation originating 
from the distention of the mouth may possibly have a similar efi'ect to 
that produced by touching the glottis or tickling the fauces. 

If it is really desired to blow air into the bronchi, then Chaussier^s 
instrument especially constructed for that purpose should be introduced 
uito the trachea, the epiglottis having been previously elevated by the 
point of the index-finger. Many and renowned obstetricians, however, 
discard the inflation of air altogether, and experiments performed upon 
new-born animals, which have been artificially asphyxiated by immer- 
sing them in warm water, also speak against it. It is rational to lay 
the child upon the right side, \nth the upper half of the body slightly 



54 DISEASES OF CHILDREN. 

elevated, because by that the right auricle will come to lie downward, 
the left upward, and thus the blood that has entered the right auricle 
mil have to mount straight upward if it desires to reach the left 
auricle directly through the still open foramen ovale instead of passing 
downward into the right ventricle. This posture may facihtate the 
closure of the fetal passage by the valve. Electricity will always be 
the surest means of causing the inspiratory muscles to contract. And, 
as the inspiratory muscles can only dilate the thorax at the expense 
of the lungs, the alveoli must therefore become filled with air, which, 
if it once properly fills and distends them, cannot escape again so 
rapidly, and will continue to act more and more as a stimulus for re- 
peated inspiratory movements ; the greatest difficulty which we have 
to contend with here is that there is " periculum in mora," and that to 
produce an electric current always requires a certain amount of time 
and knowledge which can hardly be expected of a midwife. 

All these attempts at animation are to be persevered in so long as 
the beats of the heart can still be perceived by auscultation. Not un- 
til these have been inaudible for several minutes may we abstain from 
all further attempts and pronounce the child dead. If we succeed at 
all in saving an asphyxiated child, then we usually accomplish it in 
one or at the most in two or three horn's. 

S,.— ATELECTASIS PULMONUM. 

If the inspiratory muscles do not contract sufficiently and regularly 
after the birth of the child, the lungs will also be but imperfectly and 
irregularly distended ; in some parts the alveoli will retain their fetal 
condition ; they vdll be airless and remain collapsed. This anatomo- 
pathological condition is called Atelectasis (from a priv., TeAog, the 
end, and ^ UraLg, the dilatation). 

A whole lung or an entire lobe is seldom found affected ; gener- 
ally a few scattered lobules, especially posteriorly and downward, 
are observed to be atelectic ; they are sharply defined in both lungs, 
dispersed throughout the parts that contain air, are bluish-red in color, 
and compact, do not crepitate on pressure, and sink in water ; the cut 
surfaces are smooth, regular, and not granular. The atelectic por- 
tions of a lung may be easily inflated, but these inflated parts stiU re- 
main of a darker color than of that by which they are surrounded. 
Atelectasis is satisfactorily differentiated from lobular pneumonia, by 
this possibility of inflation of the atelectic parts. In addition, the 
passages of fetal circulation in most of these children are found still 
pervious ; no trace of inflammatory exudation, however, is to be detect- 
ed in any part of the lungs. 



DISEASES CONSEQUENT ON DELIVERY. 55 

Symptoms. — Generally, the children come asphyxiated into the 
world, or at least they breathe from the time of birth but super- 
ficially and imperceptibly ; their voice is characteristic of the evil. 
They are neither able to cry loud nor continuously, but will only 
utter a few single, weak, moaning cries, and are also unable to suck 
actively or continuously for any length of time. Sometimes they 
are temporarily cyanotic, sleep much, and have a pale, cool skin. 
The pupils act slowly, are slightly dilated ; the pulse is feeble and 
slow. The percussion-sound of the thorax, when the atelectasis is 
not very extensive, is scarcely ever altered, in general somewhat less 
sonorous than in healthy new-born. Owing to the slight motions of 
the thorax, the respiratory sounds are naturally very feeble. Bron- 
chial respiration is scarcely ever heard over the atelectic portion of 
the lung ; crepitating rhonchi, however, may sometimes be detected. 
If this condition has existed for several days, spasmodic contraction 
of the facial muscles and general convulsions come on, the respira- 
tory and circulatory movements constantly grow feebler and slower, 
the skin becomes cooler, and the children either die by degrees, or 
expire suddenly during a severe tonic or clonic convulsive attack. 

Causes. — (1.) Asphyxia and all the conditions mentioned in con- 
nection with it. Atelectasis itself may be regarded as a milder de- 
gree of protracted asphyxia. (2.) Premature and feeble children. (3.) 
Authors also consider the inhalation of too cold air as a cause ; it is 
much more probable, however, that pneumonia originates from the in- 
halation of cold air ; and (4.) Too rapid and easy deliveries are stated 
to give rise to atelectasis. Atelectasis acquired some time after 
birth will be spoken of further on, in connection with pulmonary 
affections. 

Treatment. — The treatment is precisely the same as for asphyxia. 
As a prophylactic, it is of importance to cause every child, in the first 
moments of its life, to cry loud and continuously, for the purpose of 
which the remedies recommended for asphyxia are the most appro- 
priate : inflation is totally useless here, but the utmost benefit is 
derived from the cautious application of electricity to the pectoral 
muscles. As regards general rules, the children should be confined 
to a room of uniform temperature, of at least 59° F., and be kept as 
warm as possible, by warm garments and bottles filled with hot water ; 
their attitude should be changed frequently, and they should be car- 
ried about. They should not be fed with a spoon, but be made 
to suck, even if it costs them some exertion, because deep inspira- 
tions also originate through that. I once used the emetic recom- 
mended by Jorg, pulv. r. ipecac, gr. ii, but with an unhappy result, and 
since then confine myself to tickling the palate and epiglottis with 



56 DISEASES OF CHILDREN. 

the finger, once or tTvice daily, wMch induces violent retcMngs, fol- 
lowed by correspondingly deep inspirations. 

An attempt has also been made to imitate the respiratory acts by 
external pressure ; the extremely flexible thorax of the new-born is, in 
this procedure actively and gradually compressed with the hand, the 
back of the child resting upon a firm support. Neither fi^om this 
measure have I seen any favorable results, which in fact could scarce- 
ly have been expected, for these jerking compressions of the thorax 
have no more resemblance to the inspiratory movements than the 
corking of a bottle with its opening. 

G.—GEPEALJEJrATOATA.— BLOODY TUXOB OF TEE HEAD. 

Symptoms. — The bloody tumor of the head, cephalsematoma (from 
r) KE^alr], the head, and al^uc, blood), also called thrombus neona- 
torum, is a painless, soft, elastic, distinctly-fluctuating tumor upon 
the scalp, and is produced by an extravasation of blood between the 
pericranium and bone, and, for the purpose of more accurate defini- 
tion, is also called cephalhematoma subpericranium. The extravasa- 
tion most probably occurs during the delivery ; for as early as the 
first day of life, when the common caput succedaneum begins to dis- 
appear, a very distinct swelling is noticed, which remains from the 
foui'th till the sixth day, at the longest, when a tumor of the size of a 
ripe apple is discovered upon one of the parietal bones. Usually it 
is observed on the right side, and is only exceptionally met with on 
both parietal bones. They never extend over a suture. 

When this tumor has existed for several days, the finger, in travel- 
ling toward it from the normal scalp, encounters a firm bony ring 
which surrounds the base of the tumor. This is a bony exuberance 
vvhich has developed itself between the bone and the periosteum, which 
is elevated by the extravasated blood (PI. 11., Fig. 5, No. 6), and de- 
notes the commencement of absorption. Gradually the tumor loses its 
softness, and imparts to the finger a peculiar sensation or noise, due to 
a commencing formation of bone upon the surface of the pericranium 
facing the extravasation. By degTces the tumor decreases in height, 
constantly becomes harder and flatter, and, after three or six months, 
an irregularity or inequality of the bone is only detected by carefully 
feeling with the finger, and the scalp at this time may easily be 
moved over the tumor. Cephalgematoma is a tolerably rare disease, 
and occurs only once or, at the most, twice, in one thousand new-born 
children. 

Etiology. — Its cause, according to Vcdleix, seems to be the follow- 
ing : In most of the easily-delivered children, an ecchymosis of the 



DISEASES CONSEQUENT ON DELIVERY. 57 

pericranium is found, three inclies in length and two in width, extend- 
ing to both sides of the sagittal suture, more extensive, however, on 
the right parietal bone than on the left. Most probably it is due to 
the circular pressure of the dilated os uteri. In fact, these ecchy- 
moses are most frequently met with on those places where the cepha- 
Igematomae generally occur, so that the latter seem to be only a 
higher degree of those small haemorrhages which commonly occur. 

In the frequency of difificult deliveries and the rarity of cephal^ma- 
toma, it will certainly be necessary to assume an especial thinness or 
friabihty of the vessels of the cranium, in addition to this mechanical 
circumstance, and the cephalsematoma in hreech deliveries observed by 
Nagele^ Silter^ and 3Ieissnei\ show conclusively that the affair is not 
so simple as Vcdleix supposed, but that still other causes must partici- 
pate here. 

In addition to these peculiar bloody tumors of the bones of the 
head, haemorrhages upon and beneath the Galea aponeurotica likewise 
very rarely occiu" after difficult deliveries, especially as a result of the 
use of the forceps ; they are very diffuse, never have an osseous ring, 
and are more rapidly absorbed than the genuine cephalasmatoma, at- 
tended by a gTeenish and brownish discoloration of the scalp. PI. II., 
Fig. 6, exhibits a section of such a cephalasmatoma subaponeuroticum 
sive spurium. 

Finally, conjointly with the true cephalasmatoma, but also without 
it, an extravasation of blood is occasionally found upon the internal 
surface of the skull, between the bone and dura mater (PI. II., Fig. 7). 
Convulsions and paralysis are the usual consequences here of pressure 
on the brain. It is not possible to diagnose positively this meningeal 
apoplexia ; when, however, these symptoms supervene upon cephalhe- 
matoma subpericranium, then the complication of cephalsematoma 
meningeumx may be assumed with tolerable certainty. This process 
usually terminates in death. 

Besides being liable to be mistaken for C. subaponeuroticum, the 
genuine cephalasmatoma may also be confounded with : 

(1.) Caput succedaneiim^ the common tumor of the scalp. It is 
an oedema of the scalp, does not fluctuate, and pits on pressure. It 
disappears in the first twelve or twenty-four hours, whereas cephalse- 
matoma is scarcely perceptible at birth, grows from day to day, till, at 
the end of eight days, it has attained its greatest dimensions, and be- 
comes surrounded by a bony ring. The cei^halsematoma is often hidden 
by the caput succedaneum for the first twenty-four hours. 

(2.) With congenital prolapsus of the hrabi (hernia cerebri con- 
genita). Rupture of the brain never occurs on the parietal bones, but 
always between the cranial bones, in the sutures and fontanels. It 



58 DISEASES OF CHILDREN. 

bulges out more when the child cries or coughs, and easily induces con- 
vulsions. The scalp covering it is mostly thin and devoid of hair. 

(3.) With vascular tumors. These are very rare in the new-born ; 
and, when they do occur, are very seldom met with upon the scalp. 
They do not fluctuate, have a doughy feel, and no bony ring. The 
integument covering them has a bluish tinge, due to the strongly- 
developed veins beneath. 

Treatment. — The treatment may very readily be divined from the 
delineation which we have given of the course of the evil. If the 
cephalhematoma is quietly left to itself, is not squeezed, the skin cover- 
ing it is not irritated, and no surgical procedures are undertaken, it be- 
comes completely absorbed, as stated above, in from three to six 
months, the children at the same time continue to develop with- 
out any hinderance, suffer no pain when the uneven bone is pressed, 
and, in general, experience no bad effects from the entire process and 
its sequelae. 

Notwithstanding these incontrovertible facts, there are a number 
of methods of treatment which have been invented partly by surgeons 
anxious for an operation, and partly by altogether too meddlesome 
physicians. The tumor has been washed with all possible aromatic 
waters, been smeared with iodine, ammonia, and blue ointments, etc., 
etc. A mild pressure has been exercised upon the tumors by pencil- 
ling them with coUodium, or by a tin plate with which the child's 
cap was lined, caustics have been applied, setons introduced, and, 
lastly, the blood has been evacuated from the tumors by puncturing, 
slitting, or even by dividing them by a crucial incision. 

Compression, cauterization, puncturing, and incisions, only cause 
harm and danger through irritation of the scalp, and exposure to the 
air of the bones denuded of periosteum. In the so-called discussive 
treatment, the most harmless remedies are the best, and I therefore 
use only some indifferent kind of fat, which is daily rubbed upon the 
tumor. According to FurtKs report, I learn to my satisfaction that, 
for many years back, sixty-nine cases have been treated in the Vienna 
foundling-houses on the purely expectant plan, and with the best 
results. 

-D.— DISEASES OF THE NA VEL. 

After the cord has been divided, the portion remaining adherent 
to the abdomen of the child begins to dry up, and falls off between 
the third and tenth day. The time for the separation of the cord from 
the body is subject to the formation of the funis ; when it is thin, 
it will drop off rapidly ; when thick, or, as the midwives say, fat, it 
requires a longer time for the water contained in the Whartonian 



DISEASES CONSEQUENT ON DELIVERY. 59 

gelatinous substance to become absorbed or evaporated. As a result 
of the customary enveloping of the cord in a rag, and of confining it 
by the belly-band, it becomes flattened like a piece of tape, on which 
the arteries and vein are seen as three dark stripes. At the place 
where the ^^Tiartonian gelatinous substance joins the abdominal 
walls, the integument, at the shrinking of the umbilical cord, becomes 
contracted into a radiated depression, and, when the cord finally falls 
ofi^, a tolerably firm, dry cicatrix is found to have formed. In some 
instances the integument is found prolonged for some distance upon 
the cord, by which, after the latter has dropped ofiF, a disproportion- 
ately large pad and a deep funnel result, a condition that has been 
denominated " flesh navel," and is delineated on PI. I., Fig. 9, a and b. 

In fat umbilical cords, this process of cicatrization is less ad- 
vanced ; instead of the cicatrix, a red, inflamed, humid, or an actual 
suppurating surface appears, from which various pathological condi- 
tions originate. The desiccation of the cord progresses only in the 
living child ; when the new-born dies, soon after birth, the cord does 
not desiccate^ but quickly begins to rot^ and, in medico-legal autopsies, 
this point may serve as an index in determining the time when death 
ensued. 

Treatment of the Normal JSTavel. — In order to obtain a uniform 
desiccation and dropping ofi" of the umbilical cord, it is necessary to 
protect it from aU traction and maltreatment. It should be wrapped 
up in a fine soft piece of cotton or linen rag, and confined to one side 
by the belly-band. In dressing and undressing of infants, as well 
as during bathing them, all handling of the navel-string, that is con- 
stantly becoming stifi'er, should be avoided, and the attempt should 
never be made to pull or twist the cord with a view to its speedy 
removal. 

The following pathological processes occur during or after the fall 
of the cord : 

(1.) — Inflammation of the Umbilical Vessels {phlehitis and 
arteritis umbilicalis). — It sometimes happens fortunately, however, 
but rarely, that the coagulated gelatinous substance which fills 
out the umbilical vessels, beneath the abdominal muscles, becomes 
purulent, decomposed, and produces a sero-purulent discharge from 
the navel. By pressing around it, a few drops of serum may be 
squeezed out at one time. Owing to the pain and inflammation, the 
children are very restless, exercise the abdominal muscles as little 
as possible, and invariably have fever. Soon pyemic inflammations 
of the serous membranes, or erysipelas of the abdominal parietes, be- 
come superadded thereto, and the children perish, at the longest, by 
the end of the third week. When, exceptionally, no purulent absorp- 



60 DISEASES OF CHILDREN. 

tion occurs, the discharge grows less, and the navel, after several 
weeks, becomes firmly cicatrized. But, as these cases of phlebitis 
are especially observed in lying-in houses where puerperal fever pre- 
vails, it is generally followed by pyaemia and death. 

Treatment. — The treatment is very simple ; no crusts are allowed 
to form upon the suppurating surface, by keeping it constantly cov- 
ered with compresses dipped in warm water, and also by syringing 
the parts with warm vv^ater every two or three hours. The main 
indications always are the speedy removal of the child from the 
infected lying-in hospital, and to provide for it a strong, healthy wet- 
nurse, which, of course, can only be achieved in the fewest number 
of w^omen confined in a lying-in asylum. If compelled to feed the 
children by hand, milk and water, or milk with tea, w^ill serve during 
these processes to prolong life. Diarrhoea must be arrested as 
quickly as possible by muc. gi. arab. J j, with tr. opii camph. gtt. j, of 
which one or even two teaspoonfuls may be given. 

(2.) — Blennoeehcea and Ulceeation oe the Navel. — In fat na- 
vels, or in consequence of uncleanliness and maltreatment of the new 
cicatrix, it begins to discharge after the manner of mucous mem- 
branes. This, however, is readily arrested by the use of lead-water, 
compresses, or by touching the surface with lunar caustic. But, when 
this condition has lasted for some time, small excoriations begin to 
form upon the abdomen, the whole surrounding integument becomes 
inflamed, is painful to the touch, and a round ulcer, of the size of a 
penny, forms. In the worst cases, perforation of the ulcer, perito- 
nitis, and death, may follow. 

Treatment. — By the application of tepid-water compresses, and sub- 
sequently touching it with lunar caustic, cicatrization of the navel will 
almost always be attained, if the children in other respects are well 
nourished and suifer from no digestive disturbances ; in the contrary 
case, the pain and suppuration of the ulcerating navel naturally con- 
tribute to hasten the atrophy and exhaustion. 

(3.) Gangeene of the Navel. — In feeble children dehvered in 
lying-in houses, where puerperal fever prevails, an umbilical phlebitis, 
or even the just-described ulcerating navel, may become gangre- 
nous^ it becomes converted as it were into a grayish-brown sphacelous 
mass ; the gangrene rapidly encroaches upon the abdominal walls, the 
epidermis becomes loose, may be pulled off, and the cutis found be- 
neath has a gray, bluish color. Bloody serum occasionally exudes in 
tolerable quantities from between the sphacelous mass. In most in- 
stances peritonitis rapidly supervenes, and the fseces may also escape 
through a gangrenous ulcer if agglutination of a portion of the intes- 
tines with subsequent ulceration has taken place. These patients but 



DISEASES CONSEQUENT ON DELIVERY. 61 

very rarely recover ; in case of recovery, the gangrene becomes cir- 
cumscribed, tlie slough falls off, and a granulating surface remains be- 
hind. The usual termination is death in from eight to fourteen days. 

In the treatment^ unsparing cleanliness and a good wet-nurse are 
the most important agents ; chlorine-water compresses, or water con- 
taining tr. myrrh, are very useful for the purpose of eradicating the 
gangrenous odor. Pure coffee with milk and sugar, or a few tea- 
spoonfuls of Avine, will always prove the most effectual means of 
supporting the extremely depressed state of the health. 

(4.) Ulceeation of the Umbilical Stump — {Fungus Tlmhili- 
calis). — Sometimes after the cord has dropped off, and before it has 
become cicatrized, a pediculated excrescence springs up from the raw 
surface, which may attain to the size of a pea and larger, and, of 
course, hinders the formation of a cicatrix. The adjacent abdominal 
integument becomes puffy, red, and excoriated, and by neglecting 
these symptoms there is great danger of gangrene supervening. If 
excoriations have already formed, they should first be thoroughly 
cleansed, and the umbilical fold should be fully opened, so as to en- 
able one to ascertain accurately the cause of the ulceration of the 
stump, for very often it becomes covered by the puffy folds as is rep- 
resented in Fig. 8 on PI. II. If the stump and umbilical folds are 
excoriated, it might be supposed that a wound existed, and this 
erroneous supposition can only be avoided by thoroughly opening and 
carefully examining the fold. The treatment consists in abscission or 
deligation of the stump. Abscission may be performed without any 
assistance ; the umbilical fold is stretched out with the left hand, and 
the pedicle is severed with a Cooper's scissors in the right, after which 
the bleeding surface is touched with a piece of lunar caustic. In the 
dehgation both hands have to be employed, and an assistant is there- 
fore required, who is to stretch out the umbilical fold with one hand, 
while vrith a probe in the other he pushes down the ready-made noose 
as deep as possible. As the ligature is tightened it cuts through the 
stump, and here also a slight hasmorrhage takes place, but w^hich is 
readily controlled by lunar caustic. From what has just been said it 
follows that the abscission of the pedicle is much easier, simpler, and 
just as devoid of danger as the deligation. I presume that, if this pedi- 
culated stump were left to itself, it would desiccate by degrees and die, 
and a spontaneous cure would tlius take place. 

(5.) H^MORKHAGE OF THE Navel. — After the navel-cord has 
fallen off, and before complete cicatrization has taken place, highly 
dangerous bleeding occasionally occurs, which is but seldom possible 
to control. Suddenly and without any cause the belly-band is found 
to be bloody, and, when it is untied, drop after drop of blood is seen 



62 DISEASES OF CHILDREN. 

to well up out of the umbilical depression. If the blood is gathered 
up in a watch-glass it will take several days before it becomes co- 
agulated, and the coagnilum that has finally formed remains loose and 
flocculent. The children continue to bleed and perish in a few days, 
having become extremely anaemic, with petechise and ecchymotic 
spots dotting the whole surface of the body, and which at the autopsy 
are also found upon the pleurse and pericardium. This disease, on the 
whole an extremely rare one, for it only occurs once in 10,000 new- 
bom children, I have seen but once; at the autopsy the umbilical 
vein and arteries were found to be completely filled up with thrombi. 
This child died on the eleventh day, and the father informed me that 
he was the son of one who was predisposed to haemorrhage ; that he 
would bleed for days from any slight and ordinary cut, and that at 
one time he lost so much blood, after the extraction of a tooth, that 
he remained pale and feeble for many months thereafter. Hasmor- 
rhage of the navel is, therefore, with probability to be regarded as the 
first indication of a hsemorrhagic diathesis and blood dyscrasia, and 
that is probably also the reason why these cases of haemorrhage occur 
so infrequently. 

Treatment. — The ordinary local haemostatic remedies and the very 
much praised liq. ferri sesquichlor. are totally inert here, as also the 
deligation en masse advised by Dubois and Scanzoni^ accomphshed 
by deeply transfixing the navel crosswise with two needles, and 
twisting a ligature over them in the form of a figure of 8, proved in- 
effectual in my case, as the blood continued to flow from the new 
punctures made by the needles. Tho^nas Sill has cured a case by 
pouring a solution of plaster of Paris upon the freshened wound of the 
navel, and filling up the fissures and cracks originating subsequently 
with new plaster; this method is at any rate devoid of danger, 
and easily carried out, and therefore deserves future trials. The 
treatment recommended by some surgeons, to search for the umbilical 
arteries and vein, and when found to deligate them, is based upon 
the erroneous supposition that the blood comes from these vessels ; 
but the case alluded to proved that the haemorrhage had no such origin. 
If the theory of a blood cachexia is adhered to, which until now has 
had the greatest probability, it will very readily be perceived that all 
operative measures have to be discarded. 

(6.) RuPTUEE OF THE Navel — {Sernia TTmhilicalis). — By rupture 
of the navel, two conditions are briefly understood, which have scarcely 
any resemblance to each other, namely, congenital and acquired rup- 
ture of the navel (exomphalus, omphalocele congenita, rupture of 
the umbilical cord — hernia umbilicalis, omphalocele acquisita, rupture 
of the umbilical ring). 



DISEASES CONSEQUENT ON DELIVERY. 63 

Congenital rupture, or rupture of tlie umbilical cord, is due to an 
arrest in the development of the abdominal coverings, in the fissure 
of which the rupture makes its appearance. The abdominal plates of 
the embryo, which grow right and left from the primitive lines or 
stripes, are the first rudiments of the abdominal parietes ; they grow 
into the germinal vesicle, approach each other with their borders, and 
by that means enclose a cavity — the future abdominal cavity — in 
which a portion of the germinal vesicle becomes constricted. This 
constricted portion of the germinal vesicle is converted into the intes- 
tinal canal, which communicates by a passage with the portion of the 
vesicle lying outside of the belly (umbilical vesicle). This passage is 
the intestinal navel ; the borders of the still incompletely united ab- 
dominal plates surrounding it form the membranous navel {Saut- 
nahel). Now, if this constriction, which, up to the seventh or eighth 
week of fetal life, is absent, does not take place properly, the alimen- 
tary canal will develop itself in the open vesicle, will thereby keep it 
permanently open, and the liver is very much disposed to pass into the 
spacious vesicle, into which it is directly urged by the umbilical vein. 

If the portion of the bowel which is normally retained at the base 
of the navel-string does not return into the belly at the proper time, 
and continues to develop itself in the umbilical vesicle, it will finally 
attain a dimension that will also prevent its return into the abdominal 
cavity after the delivery, as fruits, which, while unripe, have been in- 
troduced into a bottle, are found impossible to be extracted when 
they have become ripe. 

But, if a part of the liver shares the umbilical opening in con- 
junction wdth the bowel, then the liver, by its density, will keep the 
ring wide open, and the bowel contained in the vesicle, through its 
increase in size, returns again into the abdominal cavity. Those con- 
genital umbilical ruptures, in which a portion of the liver does not in- 
tervene, can never be reduced, the knuckle of intestines becomes gan- 
grenous immediately after birth, after the cord has fallen off, followed 
by peritonitis and death. Congenital ruptures which contain a section 
of the liver, possibly, are capable of undergoing a spontaneous cure. 
The peritoneal coat of the liver becomes covered with granulations, 
the large opening gradually contracts, and a firm cicatrix forms. 
Debout has seen a case cured in this manner. The treatment is very 
simple : the granulating surface is covered with a piece of lint smeared 
with cerate, and the child is noiu-ished as well as possible. 

The acquired rupture^ rupture of the tirnbiUcal ring^ occurs several 
weeks or months after delivery, after the cicatrix of the navel has 
formed at the right time and in a proper manner, and is principally ob- 
served in rather lean children, who suffer much fi'om flatulence and 



Q4: DISEASES or CHILDREN. 

cry continuously. The umbilical ring is stretclied a little, and tlie 
abdominal jDressure forces a piece of the small intestines through it, 
pushing the peritonseum and the distensible umbilical cicatrix in ad- 
vance, so that a protuberance presents itself instead of the usual de- 
pression, which may attain to the size of a cherry or even of a 
small apple. A white, glistemng spot is found in the centre of the 
navel, which corresponds to the place where the three umbilical vessels 
have become united after the cord has fallen off, and has been called 
the vascular navel {Gefdss-naheT). It is less distensible than the 
onemhranous navel, and therefore is not always found upon the sum- 
mit of the rupture, but either laterally or downward. The rupture 
usually contains a small knuckle of the small intestines, which but 
very rarely pushes a portion of the omentum before itself. The re- 
duction is, in all cases, accomplished without any difficulty, after 
which the size of the ring may be ascertained with the point of the 
finger. By the use of a pro^Der truss, the umbilical ring does not simply 
decrease in size, but becomes converted, as I have often observed, into 
a diagonal fissure, the borders of which gTadually approach each other. 
I have never yet met with any incarcerations of the intestines here. 

The treatment of this rupture, which mostly also heals spontaneously, 
consists in the adaptation of a stopple made of char]Die, cotton-cloth, or 
cork-wood, but which should be a little larger than the umbilical ring, 
and securing it by pieces of adhesive plaster six by eight inches square, 
and by a belly-band, the hernia having been pre^-iously reduced. When 
the parents of the child have once been taught how to apply this apjDa- 
ratus, it may then be bathed daily and the compress is apphed again 
after each bath. I cannot agree with the opinion of some authors, 
that the rupture should be supported by long strips of adhesive plas- 
ter panning around and across the whole body, as the abdominal respi- 
rations are thereby very much impeded ; fm:thermore, there is no plaster 
that "^vill not erode the skin after a while, and it is much more difficult 
to instruct the parents how to renew this apparatus than the one 
recommended above; besides which, in the other case, the bathing 
has to be neglected for a long time, to the great detriment of the child. 
By this simple method, if assiduously apjDhed, each and every umbihcal 
ring, even though it is ever so much dilated, may be brought to a clos- 
ure in from three to six months, if the child in other respects thrives 
well. 

Y.—TFJS2fUS AXD TETAXrS OF TEE EEW-FOF:^. 

Symptoms. — {-piS/nbc, to gnash; and re-avoc, rigid com-nlsions.) Be- 
tween the first and fifth day aftet the cord has dropped off", never before 
nor later, children are sometimes attacked by trismus. Certain pre- 



DISEASES CONSEQUENT ON DELIVERY. 65 

monitory signs usually precede the attack, such as restlessness, crying, 
a peculiar trembling of the lower jaw, starting up from sleep, and 
aridity for the breast, which, however, the child instantly forsakes again. 
After these, premonitions have lasted several hours, at the most a 
day, the child is found to be unable to open the mouth. The masti 
cators are felt to be hard and tense, but the integument over them, in 
contrast with scleroma, is movable. The countenance loses the ex- 
pressionless appearance peculiar to the new-born, the mouth becomes 
pointed, the compressed lips are corrugated by striated wrinkles, the 
forehead and cheeks become wrinkled, the eyes, surrounded by a bluish 
ring', are firmly closed, the head is strongly retracted, the nape is 
stiff, the skin is turgid and reddened. The child is not able to 
swallow ; even when the jaws with difficulty have been opened and 
some fluid has been poured into the mouth, the nutriment invariably 
flows out again in a very short time. This condition, at first, has some 
intermissions ; the spasms remit for hours at a time, so that a re- 
covery may be supposed ; they, however, invariably return, constant- 
ly grow more protracted, and mostly persist till death occurs ; 
only occasionally do the contracted muscles become relaxed before 
the close of life. In the severest form of the disease, the muscles 
of the entire body become so intensely rigid, that the child may be 
raised up hke a stick of wood. Death takes place in from one to eight 
days, by suffocation or from exhaustion. The child is either choked 
in consequence of the closure of the glottis during a convulsive parox- 
ysm, or in consequence of the generally rigid, totally incapacitated 
inspiratory muscles. In the second case, in death from exhaustion, it 
is the frequent occurrence of the convulsions which produces a rapid 
sinking of the strength of the system. In protracted cases, the dej)ri- 
vation of sleep and sustenance brings about a final dissolution. 

Etiology. — In very few internal diseases can the cause be pointed 
out with so much certainty as in trismus neonatorum. A disease that 
makes its appearance only between the first and fifth day after the 
cord has fallen off, must certainly have some connection with the cica- 
trization of the navel. It is also very natural, in such a rapid con- 
traction of the tissues as takes place here, for a nerve now and then 
to become compressed, or be dragged, and thus produce all the reflex 
contractions, as we see them induced in traumatic tetanus by a foreign 
body. This will occur all the more readily if the umbilical cord was 
thick, treated roughly, and, as a result of which, ulcerations supervened. 
In most autopsies of children dying from trismus, marked morbid alter- 
ations in the umbilical arteries and vein are found, such as dilatation, 
redness, softening, ulceration of the vascular coats, pus and serum 
within and in contiguity with these vessels. 
5 



QQ DISEASES OF CHILDREN. 

In Germany, the disease occurs only in the sporadic form ; I have 
been unable to determine whether it might be more frequent at certain 
times or under certain changes of the weather. I have seen it at all 
times of the year, and under all states of the barometer, in cool and 
hot, moist and dry weather. In the Dublin lying-in houses, and in 
Mailand, trismus has been observed in an epidemic form ; it is endemic 
in Trieste, Spain, Minorca, in the West Indies, and Cayenne, ^alf 
of the children born in some of the colonies of Guiana are said to 
perish from tetanus. It not only occurs endemically in the southern, 
but also in the high northern latitudes, in Iceland, for instance, where 
the natives designate it by the name of " lock-jaw," " chinclose." And 
Mackenzie states that it rages so violently among the children born 
on Westman Eyer — islands on the southern coast of Iceland — that 
the small population is only sustained by immigration. 

Aside from the alterations in the umbilical vessels already men- 
tioned, pathological anatomy furnishes no characteristic lesions. The 
plethoric condition of the spinal cord, and the bloody effusions occa- 
sionally met with in the spinal canal, are, no doubt, secondary pro- 
cesses. The bodies retain their wood-like rigidity for some time after 
death, and even in the warm seasons feel as cold as ice. 

The prognosis is extremely unfavorable. Golis and Hehn, in all 
their extensive practice, have not seen one case recover. Hufelaiid 
puts the ratio of mortality as = .50 to 1. All of my patients, at least 
ten or twelve, died under the best methods of treatment recommended. 

Treatment. — Since, according to my experience, and that of the 
most extensively employed children's physicians, the once-developed 
trismus neonatorum invariably leads to death, it is therefore doubly 
important to pay the utmost attention to the prophylactic treatment ; 
for it mil not be easy to find a case in which, by strict investigation, 
some neglect in the care of the umbilical cord will not be discovered. 
Of course, where the affection prevails so endemically that a great 
number of the new-born are carried off by it, Frcmlc's advice is to be 
followed, according to which, the pregnant women must leave the 
dangerous region and not return until complete cicatrization of the 
navel has taken place. 

A cautious management of the umbilical cord, such as has already 
been described on page 49, and a cleanly, forbearing treatment of the 
still incompletely-formed cicatrix of the navel, to which principally 
a uniform temperature of 66 to 68° F., pure air, and healthy mother's 
milk belong, are therefore to be strictly insisted upon. 

Since it has never yet been my good fortune to cure a child of 
trismus, I am therefore unable to suggest any remedy for the fuUy- 
developed disease, and must content myself by enumerating the vari- 



DISEASES COXSEQUENT ON DELIVERY. 67 

ous metliods of treatment that have been employed and generally 
acknowledged as useless : (1.) The antiphlogistic treatment, especially 
abstraction of blood ; (2.) Antispasmodics and narcotics ; (3.) Dia- 
phoretics and coimter-irritants ; and (4.) The evacuating method. 
Each of these methods of treatment has its advocates, and each has 
its contemners. 

Of all the remedies, the narcotics are the most promising. In one 
case I gave tr. opii, one drop every hour ; in another, one drop every 
twelve hours ; in another, I used chloroform every two hours. In this 
child, the rigidity passed off during each narcotism, but returned 
in from half to one hour afterward. On the next day the symptoms 
were the same ; and, as I was about to narcotize it for the seventh 
time, I found it was dead. The most rational treatment seems to be, 
not to allow the child to perish by inanition ; which is accomplished 
by injecting, twice daily, milk or beef-tea, with yolk of eggs, into 
the stomach by the aid of a gum-elastic catheter, which is easily in- 
troduced through the oesophagus ; and to cauterize the spot that 
formed the starting-point for the trismus, the cicatrix of the navel, 
with the ferrum candens (actual cautery), a treatment which I intend 
to try in the next case that may present itself to me. 

F.—SCLFHOMA {pom o-/c\^poj, Mrd). INDUBATIO TEL^ CELLULOSE, 
ZELLGEWEBSVEEHABTUJSfa {INBTJBATION OF THE CELLULAB TIS- 
SUES). 

Scleroma, by some also called oedema neonatorum, or oedema com- 
pactum, consists in an induration of some parts of the cutis, which, in 
this manner, occurs only in the first weeks of infantile life. 

Symptoms. — The infiltration of the integument begins on the lower 
extremities, the redness of which increases while the temperature at 
the same time decreases. At first the calves of the legs swell up, and 
become perfectly stiff and hard ; the swelling next attacks the feet, 
by which the soles of the feet become peculiarly convex ; it then ex- 
tends upward over the knees, upon the thighs, to the genitals, the 
pubis, nates, and navel ; the thorax in a most remarkable manner is 
always spared ; on the other hand, the upper extremities and the face, 
particularly the lips and cheeks, which then assume a peculiar glossy 
appearance, are very generally implicated in scleroma. The dark- 
red color of the affected places, that is seen at the invasion of the dis- 
ease, very soon fades, and gives way to a yellowish; the skin be- 
comes dry, and the epidermis, which otherwise is always cast off, 
does not attain to a desquamation here. In the most intense form 
of scleroma, the child lies intensely swollen, cold, and stiff, like a 



68 DISEASES OF CHILDREN. 

frozen corpse. The hard, glistening cheek, the pufFed-up, jutting lip, 
the ejehds, that are more oedematous than indurated, and which are 
but little capable of opening themselves, disfigure the face so much as 
to make it entirely unrecognizable. At the invasion of the disease, the 
affected parts of the skin are still movable, and it is easy to make a 
depression -with the finger in the sclerous tissues, which will last for 
some time ; later, however, neither is possible. The depression of the 
temperature is very characteristic in such children, not only on the 
upper surface of the body, but also in the mouth, where, according to 
Leger's measurements, the thermometer may sink to 73° F. Artifi- 
cial warmth, by the aid of bottles filled ^vith warm water, warm 
cloths, hot baths, can only temporarily raise the temperature of the 
cold extremities, no more, in fact, than that of any other inanimate 
object. 

All the physiological functions are here either suppressed, or but 
feebly developed. The respiration is superficial and slow, the voice 
weak and whimpering ; the cry is never loud nor continuous. The 
child sucks only for a few minutes, and extracts but a small quan- 
tity of milk from the breasts. The meconium is not evacuated for 
some time, the secretion of the urine is very much diminished. The 
pulse is always very small and slow ; according to Valleix, it ranges 
from sixty to seventy-two beats per minute ; later, when the scleroma 
is far advanced, it can no more be felt in the extremities, on account 
of the induration of the integument. The action of the heart is ex- 
traordinarily feeble ; the second soimd is scarcely audible at all. The 
sensibihty of the affected parts of the skin is almost wholly gone, of 
which it is easy for one to convince himself by pricking them with a 
pin. 

As all the sjnnptoms just described but gradually become intensi- 
fied, a division of the affection into stages is therefore impossible and 
also unnecessary. The further the indurated oedema advances, all the 
more profound becomes the lethargy, all the slower the respiration, 
all the more perceptible the coldness. Finally, a bloody serum flows 
out at the fl!t)uth and nose, and death ensues without any convul- 
sions, simply by the respirations becoming slower and slower, and 
then ceasing altogether. 

In the rare cases which pass over into a recovery, deeper and 
easier respirations are at first observed, the action of the heart be- 
comes stronger and quicker, the appetite increases, and lastly a dimi- 
nution of the oedema of the indurated parts takes place. According 
to Valleix, the eyelids and upper arms are the first to become thin 
and flaccid, then the buttocks and the hypogastrium, later the hands ; 
the legs and feet remain oedematous for some time after the other 



DISEASES CONSEQUENT ON DELIVERY. ^9 

parts liare become normal. So long as the feet are still swollen, the 
subjects cannot be declared out of danger ; they sometimes become 
drowsy, drink less, and die in two or three weeks. 

The affected parts retain the violet-red color for some time after 
the oedema has totally disappeared ; the skin is weak, soft, and corru- 
gated, and does not regain its normal condition for some time. 

Lobular pneumonia is the most frequent complication; Valleix 
observed it five times in twenty-five cases. Intestinal catarrh is very 
rarely present, and that, in the difficult introduction of sustenance, is 
very readily explainable. Yellow discolorations of the new-born 
naturally frequently occur, but true icterus with yellow sclerotics, 
urine containing coloring matter of the bile, and gray fgeces, are, on 
the whole, very rare in children, nor have they any special reference 
to scleroma. 

Post-mortem Appearances. — After death the parts affected by 
scleroma rapidly become blue, and retain their hardness and rigidity ; 
the rest of the skin, especially of the trunk, is normal, yellowish-white. 
The infiltration is most marked on the side on which the body has 
been placed, as a result of the fluids sinking toward the most depend- 
ing parts. On incising the affected integument, black, semi-fluid blood 
flows out, but from the subcutaneous cellular tissue, which is so in- 
tensely oedematous, and which has produced that enormous enlarge- 
ment of the extremities, a large quantity of yellow or sanguinolent 
liquid exudes, which neither chemically nor morphologically differs 
from the ordinary dropsical serum. After this fluid has escaped, the 
indurated parts become soft and flaccid again. The connective tissue 
over the aponeurosis is converted into a gelatinous mass of two to 
four lines in thickness ; beneath the aponeurosis, in the intermuscular 
structure, no oedema is ever found. The solidification of the adipose 
tissues, which occurs when the corpse has been exposed to cold, should 
not be confounded with this condition. In that case, too, the ex- 
tremities feel hard and stiff, but they are not swollen, and are not so 
blue, and, on incising, the subcutaneous cellular tissue is found normal, 
dry, and without any gelatiniform infiltration. 

In scleroma, then, we have essentially to deal with an acute 
oedema of the skin, the causation of which is to be sought in general 
circumstances. The rest of the organs are not constantly changed ; 
most frequently serous efiiisions into the peritoneal and pleural sacs 
are found, and lobular pneumonia occasionally supervenes. Tlie fetal 
circulatory passages are sometimes closed, sometimes again still open, 
as is very frequently the case in infants who die in the first days of 
life ; scleroma, therefore, cannot be regarded as having any special 
connection with greater alterations of the circulation. 



70 DISEASES OE CHILDREN. 

Etiology, — Scleroma attacks by preference premature children. 
On the whole, it is much more easy to decide what does not produce 
scleroma, than what does produce it. It does not originate through 
the fetal passages remaining open, nor from lobular pneumonia. It 
is especially to be borne in mind that the retardations of the pulse 
and of the respirations, with the exception of those cases that are 
complicated with pneumonia, are constant phenomena. Most prob- 
ably, therefore, it is the lack of innervation of the cardiac muscle, 
which does not contract often enough, and thus produces the cold- 
ness and peripheral transudation. The disease is decidedly more 
frequent in winter than in summer. 

Treatment. — Valleix has seen two children recover, in each of 
which two leeches were applied behind each ear. Other children 
died under the same treatment. The most important part of the 
treatment seems to be to keep up constantly a high temperature of 
the body, which is accomplished by surrounding it with bottles filled 
with hot water, warm cloths, etc. It is also rational to accelerate 
the contractions of the heart by the administration of alcoholics ; on 
the whole, however, it cannot be denied that all these agents, as a 
rule, prove ineffectual, and only in exceptional cases, in slightly-dif- 
fused scleroma, do they accomplish a favorable result. 

i 

G.—MEL^NA NEONATOBUM. 

Between the first and third days of infantile life, gastric and in- 
testinal haemorrhage occasionally occurs. Vomiting of blood is less 
frequently observed than bloody, discolored f^ces. The bloody stools 
are almost always very copious, and recur at short intervals. The 
blood is sometimes fluid, and then again coagulated into large lumps. 
In this affection the patients sink very rapidly into a state of collapse, 
the lips become blue, the skin cold, the pulse is barely perceptible, 
and symptoms of acute cerebral anaemia supervene. Usually, the 
haemorrhage runs its course in twenty-four hours ; still, it may also 
last three to five days. The stools retain a dark color for many d^^ys 
after the bleeding has stopped. According to MilUet^ half of the 
children attacked by this disease recover. 

At the autopsy large quantities of fluid or coagulated blood are 
found in the stomach and intestines, and the highest degree of anaemia 
in the other organs. The fetal circulatory passages are open ; but 
this, after all, is observed in many new-born who did not die from 
melaena. The turgescence of the mesenteric arteries and their sys- 
tems of capillaries, seen even in the physiological state and produced 
by the sudden closure of the umbilical arteries, so important in the 



DISEASES CONSEQUENT OX DELIVERY. ^1 

foetus, and which arise directly from the hypogastric arteries, may be 
looked upon as a cause of this disease. An especial thinness of the 
walls, or friability of the affected system of vessels, must certainly 
play a part here ; because, otherwise, this in reality very rare form 
of haemorrhage would have to occur much more frequently. The 
closure of the ductus venosus Arantii, and especially that of the 
branch of the umbilical vein opening into the portal vein, deserves 
more frequent and stricter investigation to explain this haemor- 
rhage. 

Besides becoming bloody from intestinal haemorrhage, the feeces may 
also assume that character through blood having gained an entrance 
into the mouth of the child, and then been swallowed by it. This 
may happen in all operations on the lips and tongue, in epistaxis, the 
result of a blow upon the nose, or of that organ coming violently in 
contact with a hard substance, from the maternal blood having been 
swallowed during delivery; and, lastly, the new-born may suck in 
some blood from the breasts of the mother when any sores exist 
around the nipples, or when a strong child endeavors to suck for a 
long time from milkless breasts. All these admixtures of blood are 
very rare ; the blood in these cases is not found in large quantities, 
and usually is not ejected by the intestines, but thrown up. Nor do 
the infants sink into a state of collapse, as in actual intestinal hasmor- 
rhage. 

Treatment. — The only case of intestinal hasmorrhage which until 
now I have had an opportunity to treat, occurred in an infant thirty- 
six hours after dehvery. In the course of twenty-four hours ten diapers 
were soiled by the discharge of blood-coagula, which were of the size 
of a hazel-nut. The strong, robust child quickly turned to a waxy 
paleness, the extremities became cold, and the pulse was scarcely to 
be felt. I caused the temperature of the room to be raised to 72|-'^ F., 
laid three jugs filled with hot sand around the child, and ordered it 
to drink at the breast of the mother every hour. As in the course of 
the next twelve hours no remission ensued in the bleeding, I gave 
him — 

1^. Liq. ferri sesquichlorat. 3j. 

Aq. distillat., 

Aq. cinnamon aa, | ss. 

Syr. simple, | ss. 

Of which, in twelve hours, the child consumed about the half, and then 
discharged no more blood. I could not prevail upon myself to try the 
treatment w^ith ice-cold milk, and cold applications to the abdomen, 
proposed by JRilliet, on account of the reduction of the temperature of 
the surface of the body that must necessarily result therefrom ; on the 



72 DISEASES OF CHILDREN. 

contrary, I consider it more rational, in this intestinal haemorrhage of 
the new-born, to induce as strong a turgescence as possible toward the 
integument, which is best accomplished by a high temperature. The 
child rallied in a few days after the bloody stools stopped, and from 
that time on has prospered excellently well. 

B-.—ICTEBUS NEONATORUM {from t/crepo?, Jaundice). 

In addition to the physiological yellow discoloration of the skin 
mentioned on page 6, to which, in fact, most of the alterations of the 
color of the skin regarded as icterus belong, there is yet a condition in 
which the coloring matter of the bile is actually retained in the blood, 
and in manj^ instances it is of a very serious nature. Here the sclero- 
tica is yellow, the pus of the ophthalmo-blennorrhoea which occasionally 
supervenes turns to an orange color, and the urine dyes the diapers 
dark yellow. The faeces, however, never become as gray as in the 
adult, but retain a light-yellow or greenish tint. At the autopsy the 
serous membranes, the muscles, bones, etc., are found infiltrated with 
the coloring-matter of the bile, just as is seen in adult icteritics. Most 
of the icteritic children are feverish and suflPer from a still uncicatrized 
and ulcerating navel, with which the icterus neonatorum stands in the 
closest connection. In those cases which terminate fatally, usually 
phlebitis of the umbilical, sometimes also of the portal vein, and small 
abscesses in the parenchyma of the liver, are found. True icterus 
neonatorum is therefore to be regarded as a local condition or com- 
plication of phlebitis umbilicalis ; it is not, however, possible to main- 
tain that a duodenal catarrh or a mechanical occlusion of the bihary 
ducts may not also now and then cause an icterus. In fact, all the 
icterus of the new-born which terminates favorably belongs to this 
category. Its usual causation, according to Frerichs, is to be sought 
in a diminished tension of the capillaries of the hepatic parenchyma, 
Avhich ensues at the cessation of the afflux of blood on the part of 
the umbilical vein, and causes an augmented transposition of bile into 
the blood. 

As regards the course of the disease, every thing that has been 
said of phlebitis umbilicalis, on page 59, is applicable to the cases of 
the first category; the subjects, at the most, linger till the fourteenth 
day, become atrophied very rapidly, and mostly perish under a pro- 
fuse diarrhoea. The latter kind, the simple icterus, lasts from eight 
to fourteen days. The yellow color never becomes intense, and 
during the whole course the general condition is barely perceptibly 
disturbed. 

Treatment. — The treatment of the pernicious icterus is a most 



DISEASES COXSEQUEXT ON DELIVERY. 73 

unsatisfactory one. So far as I am aware, there is not one case of 
recovery to be found in the whole medical literature. All the more 
pleasing, on the other hand, is that of the yellow discoloration of the 
skin, falsely denominated icterus, in prematurely-born children, or 
after difficult deliveries. It invariably disappears spontaneously in 
the course of a few days, and nothing more is necessary than to pay 
attention to the digestion of the child. New-born children very 
rarely suffer from actual constipation; and, where that is the case, 
the universally beloved syrup of rhubarb will also be capable of re- 
moving the difficulty. 

l.—COXJUXCTIVITIS BLENNOBRHOICA NEONATORUM. . 

By blennorrhoic inflammation of the conjunctiva (from p/iewog, mu- 
cus, pus), we understand an inflammation that runs its course, not 
only with a profuse suppuration on the free upper surface of the con- 
junctiva, but also with an effusion of plastic exudation into the 
parenchyma thereof. The contagious, profusely-secreted pus and the 
uniform and simultaneous implication of the papillary bodies charac- 
terize this disease from all others. 

According to the severity of the affection, we distinguish two 
kinds of blennorrhoea as described by Arlt. 

First Kind. — Cases which, immediately from the beginning, are 
inclined to run a very rapid course, and display the tendency to attain 
the highest degree. 

In the first grade of this form the palpebral conjunctiva is relaxed, 
uniformly red, and secretes a tolerable quantity of pus; all these 
symptoms are present in an acute form. Often the simply purulent 
secretion ceases suddenly and makes place for a thin serous discharge, 
in which flakes and fibres swim about, frequently adhering with tol- 
erable firmness to the conjunctiva. A marked degree of swelling, 
an acute oedema of the lids, takes place here. Usually this condition 
lasts so short a time (from twelve to twenty-four hours), that the 
physician but very rarely has an opportunity to see it. 

In the second grade of this form the palpebral conjunctiva is 
dark red and very much swollen, so that the inner canthus is no 
longer sharply defined, and the absorption of the tears is prevented 
by the constriction of the punctse lachrymalis. The ocular conjunc- 
tiva, too, is already decidedly infiltrated and injected, the discharge 
is mostly like thin broth, seldom thick or purulent, and excoriates 
the adjacent integument. The oedema of the lids is so intense, that 
it is extremely difficult and painful to open the palpebral fissure. 

In the third grade, finally, all the phenomena of the second are 



74 DISEASES OF CHILDREN. 

present, only in a more aggravated form, and, in addition, an intensi- 
fied oedema of the conjunctiva bulbi supervenes. The swelling of the 
integument of the lids mounts upward over the supraorbital ridge, 
and downward extends to below the malar bone, and is uniform in 
degree from the outer to the inner angle of the eye, because, in 
reality, it is only a secondary affection of the uniformly-inflamed 
conjunctiva. The secretion is extraordinarily profuse, flows almost 
unceasingly down over the cheeks, sometimes is thin, then again 
thick, watery, or purulent, sometimes brownish, colored by an admix- 
ture of blood. The conjunctiva bulbi is either uniformly infiltrated, 
and surrounds the deeper-lying cornea like a red circular rampart or 
crown, or, in rarer instances, swells up irregularly in the form of weak, 
vesicular exuberations. 

Second Kind. — Cases which, from the very beginning, have a 
more chronic course, and are unattended by any profuse blennorrhoic 
discharge. The latter increases only after several days ; the morbid 
changes upon the entire upper surface of the conjunctivse, however, 
are marked ; granulations and minute warts form, which, in the pal- 
pebral sinuses, unite to form cock's-comb-like excrescences. 

In \)iiQ first grade of this second form the secretion is very shght; 
the red color, and the uneven state of the conjunctiva, combined 
with some intolerance of light, are its only characteristic symptoms. 
This condition may last several days without the morbid changes be- 
coming intensified. 

In the second grade the affection of the conjunctiva palpebrarum 
extends as follows : So far as the papillary bodies reach, on the lower 
about half a line, on the upper nearly one line beyond the orbital 
border of the tarsus, the highly-red conjunctival membrane is seen 
to be closely studded mth compressed, uniformly-projecting, equal- 
sized minute warts. At first, these warts bleed at almost every 
touch, but when they have existed for some time — they often last, 
when not treated, for months — they become pale on the upper surface, 
flattened from compression by the eye-bulb, and bleed less easily. 
The strongest tendency to extuberate is always seen upon the con- 
junctiva toward the orbital border, where high, cock's-comb-like granu- 
lations form. 

Here the tumefaction and redness of the lids are but slight, and 
disappear sooner than the affection of the conjunctiva. 

This form of blennorrhoea seldom attains to the third degree j 
only then, as a rule, when, during the disease, still further injurious 
influences come to bear upon the eye. The anatomo-pathological 
characters, on the whole, are the same as those of the third degree of 
the acute yjrs^ Mnd. 



DISEASES CONSEQUENT ON DELIVERY. 75 

Course. — It does not always happen that a blennorrhoea runs 
through all the three degrees ; it often stops at the second, sometimes 
even at the first. Nor is it necessary for both eyes to be implicated ; 
usually, however, the pus of the eye first attacked infects the other, 
on account of which the closure of the still sound eye, more minutely 
to be described further on, is of the utmost importance. If an actual 
transportjition of the blennorrhoic pus has taken place, as is most fre- 
quently the case in new-born children, the process then runs through 
the first and second grades so rapidly, that the physician, who is called 
in only twenty-four hours afterward, finds the third grade already fully 
developed, and the eyes, even at this juncture, may already be hope- 
lessly ruined through extensive destruction of the corneee. 

When the affection stops at the first stage, it will terminate 
slowly and spontaneously, and without any serious results. Through 
external injuries, however, it may become aggravated to a higher 
degree. 

The second grade is almost unexceptionally caused by contact 
with infecting pus. Here much less tendency to a spontaneous cure 
can be expected, as the extuberations of the papillae and the preced- 
ing suppuration thereof are liable to remain, if not treated, for many 
months. In this chronic course the lids become markedly hypertro- 
phied and enlarged ; they never, however, become shortened inwardly ; 
notwithstanding the subsequent cicatrization of the conjunctiva, an 
ectropium of the upper and lower eyelids oftener originates therefrom. 
In other cases, an abbreviation of the palpebral fissure (blepharophi- 
mosis) may form, as a result of the excoriations. In the second grade 
the cornea is but Httle endangered ; small and superficial corneal ul- 
cerations, generally, are only met with. 

The third degree, which may develop itself at any time from the 
first and second, but which may also appear very acute without any 
inflammation preceding it, is always an extremely dangerous con- 
dition. 

The Cornea^ as a rule, becomes involved. — At the first examina- 
tion the cornea may have been found to be perfectly clean, transparent, 
and glistening, but, if reexamined a few hours after, it may already 
be softened, purulently infiltrated, and in a great measure destroyed. 
"What aggravates the calamity is that this process invariably occurs 
in the centre, just opposite the pupil ; while the periphery of the cor- 
nea, with the centre remaining undestroyed, but very rarely suffers a 
solution of continuity. There is a very remarkable circumstance con- 
nected with these ulcers of the cornea, and that is, that no suj^pura- 
tion ever takes place between the corneal layers, no unguis forms. 
They have an extraordinarily great tendency to perforate, the his then 



76 DISEASES OF CHILDREN 

di'ops forward, and is quickly covered with a grayish exudation, from 
which staphyloma subsequently becomes developed. If the prolapsed 
iris and the exudation covering it are not capable of closing the per- 
foration, phthisis bulbi will take place. In general, the rule may hold 
good, that the later the affection of the cornea appeared, after the 
blennorrhoea has passed beyond the highest stage of severity, the 
less of a destructive tendency will it display. If ulcerations form, not- 
mthstanding the blennorrhoea having existed for some time, say two or 
three weeks, they will, it is true, increase in size much more slowly ; but 
nevertheless often give rise to circumscribed corneal perforations, and 
their effects, prolapsus of the iris, opaque cicatrices, anterior synechia, 
distortion of the pupil, central capsular cataract, staphyloma, etc. In 
this third and highest grade, children usually have a hot skin and fever, 
in consequence of pain and sleeplessness. 

Causes. — Those cases which are met with in private practice must 
be separately regarded from those occurrmg in lying-in and found- 
ling-houses. The extremely frequent occurrence of blennorrhoea in 
the first six to eight days of Hfe cannot possibly be attributed to 
general causes alone — glaring hght, cold, foul air, imcleanly treatment 
of the eyes, etc. — for these agents, in some measure, still remain in 
force for some weeks thereafter ; whereas the invasion of a blennor- 
rhoea after the eighth day of life, in private practice, is of the greatest 
rarity. 

Hence, an infection through blennorrhoic vaginal mucus, during the 
passage of the head of the child through the maternal passages, is gen- 
erally assumed, by which it is not necessary for sj-phihs to be present 
and participate. The infecting conditions are then the same as those 
of a gonorrhoea that has originated after an impure connection. Not 
every fluor albus, through coitus, produces a gonorrhoea, and still less 
frequently a blennorrhoea of the conjunctiva during the delivery. 
Were the latter the case, most of the new-born would suffer from the 
disease under consideration, for almost all women, during the last weeks 
of gestation, have an augmented vaginal secretion, a liigher degree of 
which represents a vaginal blennorrhoea. Moreover, the children are 
well protected against infection during dehvery by the eyelids being 
firmly closed, and by a proper coating of vemix caseosa, by which the 
rare induction of conjunctival blennorrhoea in comparison with vaginal 
blennorrhoea of the mother may be explained. That this manner of 
infection during the progress of the child through the maternal pas- 
sages is not a very intense one, follows from this, that new-born male 
children, in the first weeks of life, never acquire a urethral gonorrhoea, 
nor the female a vaginal blennorrhoea. Be that as it may, this much 
is irrefutable, that at least from eighty to ninety per cent, of all con- 



DISEASES CONSEQUENT ON DELIVERY. 77 

junctival blennorrhoeae occur in the new-born, and that in every in- 
stance the act of the dehvery, per se, may be regarded as the most im- 
portant etiological agent. 

"S^Hiere many children are congregated together, in foundling and 
lymg-in houses, blennorrhoea also occurs in an epidemic form, especially 
in those Ipng-in houses where puerperal fever prevails. Here it is espe- 
cially difficult to determine in which manner the transportation of the 
pus takes place, since it is known that sponges, towels, diapers, and 
the hands of nurses, when soiled w^th blennorrhoic pus, are capable 
of conveying the poison to healthy eyes ; the opportunities of infec- 
tion occur in such varied and manifold forms, that it is really unneces- 
sary to resort to the air, light, etc., for an explanation. 

The 2^ro(/7iosis depends entirely upon the state of the cornea. The 
granulations and the exuberations may look ever so frightful, the pu- 
rulent secretion may be ever so profuse, still all these may pass away 
without lea\dng any traces behind them ; the morbid alterations of 
the cornea, however, leave their effects for life. The earlier the 
cornea becomes implicated, all the greater is the danger of a total de- 
struction. Primary or secondary syphilitic vaginal blennorrhoea, as a 
rule, produces such intense corneal participation. The oedema of the 
lids, as a rule, stands in exact relation to the danger of the destruction 
and loss of the eye. 

Treatment. — The task of testing and criticising the various methods 
of treatment recommended by some and denounced by others is ren- 
dered difficult, by the fact that a number of violent hlennorrhoem 
disappear spo7itaneously without medication and without scrupidous 
cleanliness^ and leave behind them no morbid alterations of the 
cortiea. 

In Munich, where great negligence prevails among the lower 
classes in regard to the rearing and prosperity of the new-born, it of- 
ten happens that mothers bring to the physician their three or four 
weeks' old children with severe blennorrhoea, for some other ailment, 
and, upon closer inquiry in regard to the affection of the eye, very 
naively remark, " The jaundice attacked its eyes in the very first few 
days ; it is much better now ; at first, however, the eyes were very much 
swollen ; matter and bloody water constantly used to run down over 
the cheeks." If such untreated eyes are examined, the cornea will 
very frequently be found perfectly clean and intact. A recovery has 
taken place without any treatment. In other cases, it is true, both 
bulbs, to the great mortification of the parents, are found completely 
destroyed. These facts must be candidly premised and kept in view 
in estimating the value of the methods of treatment now about to be 
described. 



78 DISEASES OF CHILDREN. 

As a prophylactic against transportation of the blennorrhoea from 
the affected to the still normal eye, a protective bandaging is espe- 
cially to be recommended. For this pm-pose the sound eye is covered 
with a light pad of dry charpie, which is secured by a few strips of ad- 
hesive plaster. This pad and plaster should be removed twice a day 
and the eye carefully examined. If the blennorrhoea has attacked this 
eye notwithstanding, then this bandaging has completely failed in its 
object, and must be wholly abandoned in order to facihtate the escape 
of the pus. 

The most important part of the whole treatment consists in a 
thorough cleansing of the eye. In hospitals and lying-in houses where 
the children are constantly under the care of experienced persons, a 
reservoir secured to the wall with an india-rubber tube attached to it, 
by which the stream of water is conducted directly into the eye, is 
best adapted for this purpose. The temperature of the water should 
not be higher than the temperature of the room. In private practice, 
with proper care, the water may be injected into the eyes with a 
syringe ; or it is allowed to flow into them from a small, narrow-spouted 
can, which procedures must be repeated at least every hour. A toler- 
able amount of adroitness is requisite to properly manipulate the 
sjTinge ; usually the nurses throw the water upon the firmly-aggluti- 
nated eyelids, and, of course, as much pus remains beneath them after- 
ward as before. I consider it very inappropriate to hold the lids apart 
by means of spatula every time the eye is cleansed, because such an 
intense oedema is thereby produced in a very short time, that the upper 
eyelid comes to drop far do^^m over the lower, and then it is altogether 
impossible to obtain a sight of the globe. In consideration of these 
difficulties, and because mth the syringe people very often throw the 
blennorrhoic pus into their own eyes, and thereby lose their o\yn \as- 
ion, I content myself ^vith cutting up a fine sponge that has already 
been in use for some time, into angular pieces and with these cause 
the eye to be sponged every half hour or hour. The nurse should 
hold the lids open with the thumb and index-finger of the left hand, 
while mth the moistened sponge in the right she brushes over the 
conjunctiva. This manipulation every person with a good-will can 
learn to execute ; it also completely suffices to cleanse the conjunctivae, 
and the pillow and child's garments are not thereby soaked through, 
as is usually the case with injections. 

The Local Treatment. — Ever since yon Grcife so strongly recom- 
mended the application of nitrate of silver, almost all blennorrhoic 
conjunctiva have been cauterized. First of all, it should be observed 
that, for the purpose of thoroughly cauterizing the eyes, it is necessary 
to have an assistant, who should fix the head and properly evert the 



DISEASES CONSEQUENT ON DELIVERY. 79 

eyelids.* Either the ordinary nitrate of silver or a mitigated caustic 
composed of equal parts of nitrate of silver and nitrate of potassa fused 
together is used for this cauterization. A little olive-oil or salt water 
will prevent the caustic from spreading unnecessarily. The secretion, as 
a rule, is somewhat checked after the cauterization ; it appears again, 
however, on the next day more profusely than ever. The eyes are 
cauterized from day to da}^, until the disease gradually disappears. 
Both eyelids should be brushed over every time with the caustic as far 
back as the orbital reflexion, because the whole conjunctiva palpe- 
brarum is involved in the disease. That this method of treatment is 
painful, and that for this reason the women do not bring their children 
to be cauterized a second time, cannot be denied. Moreover, I have 
often seen perforation of the cornea ensue, notwithstanding the most 
carefully carried out precepts. Blennorrhoea of the conjunctiva seems 
to be an analogous process to gonnorrhoea of the urethra. A few 
years ago surgeons were very enthusiastic over nitrate of silver 
injections in gonorrhoea too. Now, no one resorts to them any 
more. 

A coUyrium of corrosive sublimate, or sulphate of zinc or of cop- 
per, gr. ss of the first, gr. j of the last two, to an ounce of water, is 
less painful and about as efi"ectual as cauterization with the solid stick 
of nitrate of silver. One drop of any of these collyrise is dripped into 
the inner angle of the eye, six or eight times daily; the lids are 
slightly opened, and the head is held in such a position that the drops 
will run into the eye by their own gravity. The sovereign remedy in 
the first days of blennorrhoea is 

Cold. — But to generate continuous cold upon a given spot on the 
skin is not as easy as may be supposed. Compresses dipped in cold 
water, and laid upon the skin, assume in a very short time the tem- 
perature of the skin itself. They would therefore have to be renewed 
so frequently that more than one nurse would be required. But if 
two or three bits of ice, as large as peas, are placed between the 
moistened folds of the compress, the melting pieces of ice will keep 
the temperature of the eyelids reduced for eight or ten minutes. So 
small a quantity of ice, on melting, does not generate water enough 
to run down over the cheeks, and whatever there is of it is absorbed 
by the compresses. As a sure protection against wetting the bodj^, 
a dry cloth around the neck is very useful. By continuously-gener- 
ated cold, the oedema of the lids may generally be reduced, and the 

* Still, the assistant may be dispensed with, bj'^ the physician securing the head of 
the child between his knees ; he then everts one eyelid, which he retains everted 
with the thumb or index-finger of the left hand, while with the right he is at liberty 
to handle the caustic. The other eyelids are then similarly treated. — Tk. 



80 DISEASES OF CHILDREN. 

blennorrlioea kept within moderate bounds. By constant, scrupulous 
cleansing, an astringent eye-wash, and, when the secretion lasts 
longer, by the inunction of blue ointment upon the forehead, the 
cornea will be kept from perforation. Warty excrescences in the 
palpebral sinuses, where the blennorrhoea is nurtured for a very long 
time, are best removed with the scissors. If perforation and prolapse 
of the iris have taken place, staphyloma at least may be prevented by 
energetic cauterization of the cornea, and constant pressure. In cir- 
cumscribed central leucoma, the sight at a later period may be in- 
finitely improved by the formation of an artificial pupil. If phthisis 
bulbi (atrophy of the globe) has occurred, the deformity may be miti- 
gated by an imitation eye, in the perfection of which, art of late has 
made such extensive progress. 



CHAPTER II. 

DISEASES OF THE DIGESTIVE APPARATUS. 

K.—MOUTE. 

(1.) Hakelip axd Cleft Palate {Labium Leporiniim — Palor 
tum Fissmn). — Harelip is a congenital splitting of the upper lip ; cleft 
palate, a congenital fissure of the hard palate. In order to thoroughly 
comprehend these malformations, it is necessary to revert to the his- 
tory of the fetal development. 

As long as the two superior maxillas remain ununited in the me- 
dian line, with the intermaxillary bone that has originated from the 
central process of the frontal bone, to form the hard palate, so long 
will the mouth and nasal cavities stand in open communication mth 
each other. 

Now, in cleft palate, this union is arrested on one side ; in hare- 
lip, a union between the bones does indeed take place, but seems to 
have been retarded, on account of which, the upper lip, which is 
formed primarily of two lateral and one central piece, does not become 
united ; the fissure of the upper lip, corresponding to the one in which 
the union has been arrested, becomes skinned over like the borders of 
the lips, and union is subsequently altogether impossible. From these 
remarks, it will be readily perceived why harelip never occurs in the 
centre of the lip, but always on one side : the chasm invariably ter- 
minates in one or the other nasal cavity. 

We have various grades of fissures, according to the time in 
which, during fetal life, this arrest of development has taken place. 



DISEASES OF THE DIGESTIVE APPARATUS. gl 

The cleft of the hard palate may be so wide as to easily admit a finger, 
and all the infundibuli may be inspected without any difficulty. In 
this intense form, scarcely any upper lip is present, and one or both 
nasal orifices are immensly distended. Or the intermaxillary bone, 
covered with some skin, projects forward, and forms a knob under 
the nose. At each side of this bulb, fissures of the lip run into the 
nasal orifices. Or there is only a narrow fissure in the hard palate, 
which will barely admit the back of a knife, and, corresponding with 
it, the cleft in the upper lip is also less grave. Or both upper jaws 
are perfectly normally formed, and there is only a narrow fissure in 
the upper lip, the margins of which almost touch each other, 
and either extend clear into one of the nasal openings, or only half 
way to it. 

There are families many members of which are deformed by hare- 
lip, so that we are compelled to assume a kind of predisposition or 
inheritability. 

The efi"ects of this evil are : 

(1.) Difficult Sucking^ i^articularly in Cleft Folate. — The act of 
sucking consists in the lips locking themselves hermetically around the 
nipple ; the air in the mouth becomes rarefied by the dilatation of the 
thorax, and the milk is in this manner pumped out from the breasts. 
But, when the continuity of the lips is broken, they are unable to firmly 
and perfectly adapt themselves around the nipple, and infants are 
then incapable of exhausting the milk. When the hard palate is not 
simultaneously fissured, children will grasp the nipple between the 
jaws, instead of the lips, and in that way suck with tolerable ease. 
But when cleft palate is also present, then they are almost alto- 
gether unable to nurse ; the overflowing breasts do indeed discharge 
some milk into the mouth, but the greater part flows out again at 
the nose; this is best prevented by holding the head of the child 
elevated. 

(2.) Ohliquity in the Position of the Teeth. — If the operation is 
not performed before the eruption of the teeth, or if it has been un- 
successful, the teeth of that part of the jaw that is not covered by 
lip will grow crooked, outwardly instead of downward; this is es- 
pecially true when cleft palate also exists, which gives to the face a 
hideous disfigurement. 

(3.) Indistinct Speech. — Some letters, to the articulation of which 
the upper lip is indispensably necessary, principally B, M, P, W, are 
but indistinctly pronounced in harelip, and are altogether impossible 
of articulation in cleft palate. In the latter case, all the other conso- 
nants in addition lose in distinctness on account of the defect of the 
palate. 



32 DISEASES OF CHILDREN. 

Treatment. — Nothing but an operation can remedy tliis deformity. 
x\s regards the time when it is to be performed, much has already been 
written and disputed. If the nutrition of the child is much interfered 
with, if it does not learn in the first few weeks to suck and swallow 
properly, then of course it will remain backward in its development, and 
the operation must be performed as soon as possible. But, when this 
is not the case, it is best to wait until the child has passed the fourth 
month. At all events, however, the operation should be performed be- 
fore the eruption of the teeth, for, as soon as dentition has once begun, 
children are oftener subject to sickness, and on that account the result 
often proves a failure. Moreover, children more than six months old 
begin to use their hands, with which they may tear down the plaster 
after the operation, or entangle them among the points of the pins, 
and thus frustrate its success. 

Before the operation, the child is to be kept awake for several 
hours, in order that it may subsequently fall into a deeper sleep 
than usual ; and it is also to be nursed, so that thirst or hunger may 
not rouse it too soon. It is best to wrap the entire body up to the 
neck in a sheet, and then place it in the lap of an assistant. Nothing 
more is necessary for the operation than a sharp tenaculum, a strong 
sharp scissors, the sewing apparatus, and a few strips of adhesive plas- 
ter. A second assistant now seizes a part of the split lip between his 
thumb and index-finger and compresses the vessels. The operator, 
seated opposite the child, seizes hold of the border of the lip with the 
tenaculum where it passes over into the fissure upwardly, pushes 
the scissors into the slit, and mth one cut removes the entire edge. 
The same manoeuvres are repeated on the other side. After the edges 
have been adjusted, two or three needles, the lower ones first, are in- 
troduced, and a few turns of the ligature taken around each one of 
them. 

In wide-cleft palates, where scarcely any upper lip exists, the 
cheeks will have to be separated from the bone very far backward, in 
order to obtain a sufficient amount of distensible substance. All pro- 
jecting teeth and bony outgrowths must, under all circumstances, be re- 
moved before the operation, and the wounds should first be allowed 
to cicatrize. The ligatures should not be drawn too tightly, for the 
circulation in the margins of the wound will thereby suffer severely, 
and an insufficient amount of plastic material will be thrown out. 
In my first operation for harelip, I drew the ligatures very tightly, in 
order to adapt the edges very accurately. In twenty-four hours the 
child was seized with trismus and tetanus, and the needles, of course, 
had to be removed as quickly as possible. The trismus then disap- 
peared, but the success of the operation was frustrated. 



DISEASES OF THE DIGESTIVE APPARATUS. 83 

After from fortj-eight to sixty hours, the needles, which should 
have been previously brushed over with a little oil, may be removed ; 
the twisted suture may remain adherent for some time longer. In 
double harelip, with large central piece, an attempt should be made to 
save it. In cleft palate, where frequently one border of the notch is 
shorter than its fellow, a curved incision should be made on the shorter 
one, by which the borders of the wound will become equal in length. 

Even when the operation has been entirely successful, in the 
course of time, a cicatricial contraction and a visible notching of the 
upper lip result. The success of this operation is of the utmost im- 
portance for the future shaping of the cleft palate. The united upper 
lip then constantly acts as a mild truss upon the fissured upper jaws, 
approximates them more and more to each other, till they finally touch, 
when the mucous membrane, by mild cauterization, or by baring the 
edges with a knife, may be brought to a union. 

(2.) Cois^STEiCTioi^ OF THE MouTH — Micvostoma (from ixLKp6g^ 
small, and o■^(5/^a, mouth). — An exceedingly rare afi'ection. Some chil- 
dren come into the world either with a very small mouth or with 
completely united lips, in which latter case it is of itself understood 
that an operation for the formation of the mouth must be undertaken 
in the very first hours of life. A more frequent occurrence is contrac- 
tion of the mouth from syphilitic mucous patches, and chancres. The 
cicatrices contract more and more, till, finally, it is impossible to intro- 
duce a small spoon, or even a tube. If the syphilis has been eradi- 
cated from the system by a mercurial treatment, the formation of the 
mouth may be undertaken according to Diffeiibach^ s method. A 
myrtle-leaf-like piece of skin is excised from the cicatrix, at both 
sides of the constricted mouth, without injuring the mucous membrane, 
thus forming the future angles of the mouth ; next the mucous mem- 
brane is cut through with the scissors clear to the angles, is lapped 
over the edges of the wound, and united to the outer border by su- 
tures. If the subjects are not marasmic, which, however, is their 
usual lot after they have surmounted syphilis, the operation w^ill 
readily succeed. In the contrary case, the mucous membrane will 
not heal, but becomes covered with an aphthous membrane, and the 
patients perish in an atrophic state. 

(3.) Impeefect Development of the To:n^gtje [Defectus Lin- 
gum). — Instead of the normal oval form, the tongue occasionally dis- 
plays an indentation at the apex, or even a more extensive fissure. 
Complete splitting of the tongue, where two movable tubercles or 
bands are seen at the back of the mouth, is very rarely observed. 
Children thus afi'ected, according to JBednar, are able to cry, and 
the sense of taste is said to be present. According to embrj'ology. 



S4: DISEASES OF CHILDREX. 

this malformation is explainable in the following manner : The devel- 
opment of the tongue proceeds from the first visceral arch. A'^Tien 
the bulbous ends of the visceral arch meet in the median line, and be- 
come united to each other, a small tubercle is seen to develop itself on 
the lower border of the posterior surface of the first gill-arch, at the 
place of union of the two halves, which at first has a triangular, later 
an oval form, and gradually becomes developed into an anteriorly- 
cijirved, fieshy cone (the tongue). But, if tliis union of the visceral 
arch did not take place perfectlj^, and at the right time, that fleshy 
cone will remain divided, and, as an effect thereof, is retarded in its 
general development. 

(4.) Htpeeteopht and Prolapse op the Toxgue {Prolapsus 
Linguce). — The tip of the tongue only is seen protruding beyond the 
lips at birth ; the j^rotruding piece, however, if nothing is done, 'will 
increase in size from day to day. Such children are unable to suck, 
and also hindered in swallowing, for the tongue not only hypertrophies 
anteriorly, but also in width and thickness. This enlargement of the 
tongue is usually combined with cretinism. When the dentition period 
arrives, the incisors are prevented from assmning their perpendicular 
position, and are directed obliquely forward. The constant pressure 
of the teeth produces an intense infiltration of the tongue : it ulcer- 
ates, becomes furrowed, the saliva constantly flows down over it, un- 
dergoes decomjDOsition, and diffuses a disgusting, sour, rancid, fatty 
smell. In cases of many years' duration, the inferior maxilla forms a 
gutter, in which the ulcerated or dry tongue lies. The lower lip be- 
comes everted, and the acquisition of distinct speech is wholly impos- 
sible. This condition is also met with in children well-develoiDed in 
other respects, who have frequently suffered from convulsions, by which 
a weakness or partial paralysis of some of the muscles of the tongue 
may remain. 

Treatment. — If the evil is recent, and the tongue reducible, the 
cure is soon effected by dusting powdered alum on the protruded 
part, or painting it with tr. amara. But, when the tongue cannot be 
reduced in this manner, and the mucous membrane is already ulcer- 
ated and fissured, the projecting piece will have to be removed by a 
surgical operation. Hitherto, the ligature or knife was employed 
in this operation ; in most instances it is now performed with the 
ecraseur, but most c^uickly and elegantly with the galvano-caustic 
apparatus. 

(5.) Aexorafat. Adhesions of the Toxgue {Adhcesio Linguc^. 
— There are cases in which the fraenum is short, and yet inserted very 
far anteriorly at the tijD of the tongue, by which that organ is much 
hindered in its motions, especially in its protrusions, and in sucking. 



DISEASES OF THE DIGESTIVE APPARATUS. 35 

Tubercles in and hypertropliies of the frEenmn also occasionally 
occur, and exercise the same effect upon the tongue. Frseni, which 
are so constructed, must be severed by the snip of a scissors, if the 
sucking has actually been interfered with ; this, however, is usually 
not the case. The frjenum is divided hundreds of times where it is 
once really indicated. But, as this operation, when performed by a 
steady hand, is totally devoid of harm, it is therefore not necessary 
to look so strictly for the indications, especially if any comfort can 
thereby be conferred upon the patients. This little operation is per- 
formed in the following manner : The head of the child, facing the 
window, is held by some person, while the surgeon pushes the index- 
finger of his left hand under the tongue, close by the fraenum, makes 
the latter a little tense, and cuts it through with a curved Cooper's 
scissors as far as it is membranous. The hsemorrhage soon ceases. 

But, in addition to this shortening of the frasnum, there also occurs 
an actual union of the whole lower surface of the tongue on all sides 
with the floor of the mouth, either congenital, as a continuation of 
the embryonic union of the tongue with the floor of the mouth, of 
which the normal superfluity of the folds of mucous membrane on 
both sides of the frsenulum represents the so-called plica fimbriata, 
or acquired through syphilitic or mercurial ulcerations. Fortunately, 
this is a tolerably rare occurrence. The separation of the entire 
tongue with the knife is a very bloody operation, and often leads to 
no satisfactory results, if the after-treatment, consisting in the con- 
stant introduction of pledgets of lint, and frequent passive motion 
of the tongue, is not assiduously carried out. The galvano-caustic 
promises better results. 

(6.) Raxt:la. — By ranula, frog-swelling, we understand a cystic 
tumor with fluid contents, found beneath the tongue on the floor of 
the mouth. It occurs on one or both sides of the frsenuluni linguae, 
its size varies between that of a pea and a pigeon's egg ; in the latter 
case, it may also be felt externally beneath the chin. The mucous 
membrane covering it is often so atrophied that the walls of the cyst 
lie freely exposed. In other cases, the tumor lies much deeper on 
the anterior and lateral parts of the neck under the mylohyoid 
muscle. The effects of this evil vary according to its size. So long- 
as the tumor is not larger than a pea, it gives rise to no phenomenon. 
But, as it increases in size, it compresses the tongue against the hard 
palate, and then sucking, swallowing, and breathing, are rendered 
difficult. In the most intense form of this evil, attacks of suffocation 
ensue which have some resemblance to those of croup. It is gener- 
ally supposed that this affection can only be cured by a surgical 



86 DISEASES OF CHILDREN. 

operation ; but a spontaneous cure may also take place by suppura- 
tive degeneration of the cyst and its adjacent structures ; of this, the 
following case taught me : 

A mother rushed breathless into my office, with a boy one and a 
half years old in her arms. She related that he had always been 
well, but of late had a peculiar rattling in the throat during sleep, 
and, for the last eight days, attacks of suffocation, which, accord- 
ing to her ideas, had some connection with the dentition, because 
he was suffering from profuse ptyalism, and often put his hand 
into the mouth. "WTiile the woman was making these statements, 
I commenced to examine the child. The forehead was hot, the 
pulse very rapid, the respirations loud, like those of croup, the ex- 
pression of the face anxious and suffering. As I introduced my 
finger into the mouth, for the purpose of examining the pharynx 
and tonsils, he was seized with a sudden fit of choking, and, as I, 
on that account, depressed the tongue, I felt something burst, and 
the size of the tongue instantly decreased. At the same time, a 
tolerably large quantity of muco-purulent fluid flowed alongside of 
my hand from the floor of the mouth, which had its source in the 
ruptured cyst beneath the tongue. I thoroughly cauterized the 
collapsed cyst with lunar caustic, and it became converted into an 
obstinate ulcer, which healed, only after many months, with a white 
cicatrix. 

Various theories are entertained in regard to the nature of ranula. 
Aside from the somewhat too keen theory of old Pare^ who con- 
sidered it " as cold, moist, gelatinous matter derived from the brain, 
and transplanted to the tongue," it is looked upon by some as a 
cystic swelling of unknown origin ; while others regard it as an 
occlusion, and subsequent distention of the duct of the submaxillary 
gland, the ductus Whartonianus. This latter theory, suggested by 
Munincks^ and adopted by many others, has too serious grounds 
against it to retain any further value. A priori reasoning would 
favor this supposition ; it finds a justifiable analogy in the dacryocys- 
toblennostatis, but chemical investigations have shown that the fluid 
of the ranula is not saliva, for albumen is found in it, which does 
not exist in saliva, while rhodium-kali, characteristic of the latter, is 
here totally absent. The reply, that the chemical synthesis may not 
be able to produce the exact proportions, because the saliva, long con- 
fined, may take up new chemical bodies, and, by exosmosis, give off 
primitive ones, is made invalid by the anatomical knife. Accord- 
ing to Hyrtl^ ranula has already been found near the healthy un- 
dilated salivary duct. Ranula, consequently, is no dilated ductus 
Whartonianus, but a cyst ; and, since, according to Fleischmann, a 



DISEASES OF THE DIGESTIVE APPARATUS. 87 

mucoiis bursa exists under the tongue, it is probably a dropsical 
mucous bursa, or ganglion. 

The prognosis, according to these anatomical conditions, and also 
in conformity with experience, is not unfavorable, chiefly because the 
diseased parts are within easy reach. 

Treatment. — It consists in the removal of the anterior part of the 
cyst, and frequently-repeated cauterizations of the opened cavity with 
a soHd stick of nitrate of silver. A simple incision into the cyst and 
evacuation of its contents do not answer, because the cyst is very 
prone to close up again ; this is still more promoted by the pressure 
of the superlying tongue. A very torpid ulcer results from the cavity 
that is thus exposed, which does not close up until it has been repeat- 
edly and intensely cauterized. 

(7.) Cataerhal Intlammatio:n' of the Mucous Membeane of 
THE Mouth {Stomatitis Catarrhalis). Symptoms. — By catarrhal sto- 
matitis are meant redness and augmented secretion of the mucous 
membrane of the mouth. On those places of the mucous membrane 
which have a feeble and rich substratum of connective tissue, the red- 
ness attains to a much higher degree than on those which lie directly 
over the bone, for example, on the hard palate, where it is generally 
but slightly increased. It is most intense on the tongue, which has 
the appearance as if it were covered over by a thick coating of rasp- 
berry syrup. When the process lasts long, the tongue becomes cov- 
ered with a white fur. In fact, even oedema of the mucous mem- 
brane supervenes here ; it is, however, so slight, that it produces no 
change in the form of the cheek and lips, as is the case, for instance, in 
stomacace. 

The pain is here very distinctly marked. The patients suck unwill- 
ingly ; partake on the whole of but very little, and only cold nutri- 
ments, and do not allow their mouths to be felt with the finger. As 
this stomatitis catarrhalis is but very seldom idiopathic, and generally 
the accompaniment of other, in greater part febrile processes, it is dif- 
ficult to determine its influence upon the general state of the system. 
Nervous children are also feverish in simple stomatitis, although un- 
affected by any other disease. Wlien the inflammation of the mucous 
membrane of the mouth extends over the larynx, nasal passages, the 
Eustachian tube, and tympanum, it produces the well-known phe- 
nomena of catarrhal laryngitis, coryza, catarrh of the Eustachian tube 
and of the tympanum, any one of which suffices to induce febrile ex- 
citement. The pain, during nursing and drinking, at times is so great, 
that children will partake of scarcely any nutriment for days ; nutrition 
and development are thus totally interfered with. 

The secretion of such a morbidly-changed mucous membrane is 



88 DISEASES OF CHILDREX. 

always augmented, the saliva constantly flows out at the corners of 
the mouth, corrodes them, reddens the chin, and soaks through the 
garments. This saliva does indeed smell somewhat acid, and reacts 
also feebly acid ; it never, however, has that disgusting odor which is 
perceived in actual suppurations of the mucous membrane. 

If the redness and painfolness have existed for some time, and the 
cause still continues, clear, minute water-vesicles, like true exudations, 
will rise upon the tongue, gums, mucous membrane of the lips and 
cheeks, which in appearance and course have many similarities to 
herpes labialis. They burst very soon, and leave behind them small, 
flat ulcers, with yellowish-white bases, which, in the first few days, 
increase in every direction, become confluent, and thus present toler- 
ably extensive ulcerated surfaces, especially on the edges of the tongue 
and on the mucous membrane of the hps — stomatitis ulcerosa. — These 
minute vesicles, like almost all diseases of the mouth, have been called 
" aphthae," a term that has produced so much confusion, in the de- 
scription of the diseases of the mouth, that it seems advisable to dis- 
card it altogether. 

After these ulcers have continued to increase in size for several 
days, and produced severe pain when touched, the yellowish color of 
their bases disappears ; they become red, and covered as it seems 
directly with epithelium ; at any rate, the recovery takes place so rap- 
idly, often in two or three days, that a cure by cicatrization, and con- 
traction, is not supposable. 

These ulcers never diffuse any particular odor. The breath of 
those afi'ected with it smells only slightly acidulous, never nauseating, 
as in stomacace. 

The most common cause is the eruption of the teeth. During this 
process stomatitis occurs so regularly, that it must be regarded as 
physiological. A further frequent cause is to be found in the sucking- 
rag with its fermenting contents. In older children, too hot or too 
cold nutriments, carious teeth, spiced, irritating victuals, in some chil- 
dren antimonial and iodine preparations, may also give rise to this affec- 
tion. It also occurs in small epidemics, chiefly in summer, caused per- 
haps by the immoderate indulgence in sour fi'uits ; and, in addition, is 
also the accompaniment of many febrile diseases, especially of the 
acute exanthemata. 

Treatment. — The treatment is extremely simple. The causes, 
the sugar-teat, etc., are removed as well as possible, the chest is 
protected against getting wet by a piece of oil-silk which is secured 
under the jacket, and the infants are only allowed to drink cow's milk 
with water. 

It is ad\dsable, on account of the profusely secreted saliva rapidly 



DISEASES OF THE DIGESTIVE APPARATUS. 89 

becoming sour, to cleanse the mouth every hour with a feebly al- 
kaline solution; for instance, borax 3 j, to water 3 j. The painful 
ulcers may be relieved for many hours, and even permanently, by 
cauterizing them with the solid nitrate of silver. In idiopathic 
stomatitis spontaneous recovery takes place in eight, at the longest 
fourteen days. Symptomatic stomatitis in febrile diseases is not 
usually a subject of special treatment. 

(8.) DiPHTiiEEiTis OF THE MouTH (from 6c(i)&ipa, skin, and itis). — 
By diphtheritis or diphtheria, angina membranacea, angina couen- 
neuse of the French, is understood an acute general affection, the 
most striking symptoms of which consist in an extensive for matio7i 
of membranes on the posterior parts of the mouth. 

Historical investigations have shown that the disease is by no 
means new, and that it was already known to Aretceus (second half 
of the first century A. d,). There are also descriptions extant of 
epidemics in Holland (fourth century), in Paris (sixteenth century), 
in Spain (seventeenth century), and in the present century it occurred 
most frequently in America, next in England and France, and 
lastly in Germany, and indeed predominantly in the northern part 
thereof. 

A primary and a secondary diphtheria are distinguished, of 
which the latter associates itself particularly with measles and scar- 
let fever, and occurs in a sporadic form, whereas the primary al- 
most unexceptionally prevails epidemically, and is decidedly con- 
tagious. 

Symptoms. — Primary diphtheria invariably begins with fever, 
marked acceleration of the pulse, increase of temperature of the skin, 
and .general depression. Still, these phenomena in different in- 
dividuals are extremely unequally developed ; this inequality, in 
fact, is only a special peculiarity of this disease, since its occur- 
rence and course, under equal circumstances and in equal ages, vary 
immensely. 

The local symptoms make their appearance after these general 
phenomena have existed for a few hours, or at the longest one or two 
days. The patients are attacked by dysphagia, a snuffling, somewhat 
hoarse voice, and stiffness of the neck ; the first two symptoms are due 
to the diphtheritic exudation coating the tonsils, palate, and nares, 
the last to the never-abseyit swelling of the adjacent lymphatic 
glands of the neck. 

If the mouth is now examined by the aid of a good light, it will 
be seen that the mucous membrane of the lips, gums, cheeks, and of 
the hard palate, is perfectly intact, but that the soft palate, the tonsils, 
and the posterior wall of the pharynx, are covered with a white mem^ 



90 DISEASES OF CHILDREN. 

brane, which, especially upon the tonsils, may attain to one-half and even 
one line in thickness. The color of this membrane at first is perfectly 
white, but after several days it passes over into a yellowish-white 
or grayish-white tint. If the affected parts have been injured by 
escharotics or rough handling, small hsemorrhages ensue, in conse- 
quence of which the membranes assume a bro^vnish or even black- 
ish color. The course of these membranous formations varies ac- 
cording to the character of the epidemic. There are instances where 
the membranes have been cast off in two or three days, and the 
mucous membrane beneath was seen to be uninjured; there are 
other cases, and these form the generality, where the membranes 
exist for two and three weeks, the mucous membrane is thereby 
drawn into a process of ulceration, and heals only after a protracted 
period, with visible cicatrices ; and finally malignant cases occm-, in 
which gangrene soon manifests itself, followed by general collapse, the 
mucous membrane undergoing a black destructive degeneration. In 
this last unfavorable form, marked destruction of tissue takes place, 
usually quickly followed by death, and a recovery is but very rarely 
brought about. 

If the membranes can be seen upon the places mentioned, then, 
of course, no doubt can be entertained in regard to the diagnosis. 
But in some particular cases a redness and slight swelling of the 
fauces only are noticeable, and yet all the subjective and the rest of the 
objective symptoms of diphtheria may be present. Here we have to 
deal with an exudation upon the posterior surfaces of the u\nila, soft 
palate, and of the nasal caidties, as may be demonstrated by ele- 
vating the soft palate with a forceps, certainly accomphshable only 
in adults, and by the discharge of a profuse reddish-colored mucus 
from the nares. I have often convinced myself, at the post-mortem 
examination, that the anterior surface of the soft palate may remain 
perfectly free, while the posterior, on the contrary, may become 
coated with membrane. By far the most dangerous, and, in some 
epidemics, unfortunately also the most frequent phenomenon, is the 
extension of the membrane into the larynx^ which will be treated of 
more minutely further on, in the chapter on croup. 

Diphtheria is no local disease, for otherwise the vagina, excoriated 
surfaces on various parts of the body, the conjunctivae, and sometimes 
also the anus, would not become simultaneously coated with false 
membranes. 

The most common complications and sequelse to be mentioned are 
aTbuminuria and nephritis^ croup^ hronchitis, and pneumonia^ intes- 
tinal catarrh^ myocarditis^ and finally a pecuhar paralysis. 

Albuminuria is said to have been observed, in severe epidemics, 



DISEASES OF THE DIGESTIVE APPARATUS. 91 

fi-om the very commencement of the disease ; in the ordinary epi- 
demics, such a one as I witnessed in Munich in 1864, the urine at first 
is free from albumen, dark in color, and sparingly secreted. But 
later on, when the diphtheria has completely exhausted itself, a 
true nephritis occasionally supervenes, which, so far as the morbid 
changes in the urine are concerned, cannot in any way be distin- 
guished from nephritis occurring after scarlatina. The urine has a 
blood-red color, contains a large quantity of blood-globules, epithe- 
Hum cells and casts, and, on boiling, reveals a correspondingly large 
precipitate of albumen. But whereas in nephritis, after scarlet fever, 
anasarca and effusion of serum into the serous cavities, rapidly and in 
a critically high degree, take place, here, as a rule, the extremities do 
not swell, and dropsical effusions into the large serous sacs are 
still more rarely met with. Usually, this nephritis terminates in 
recovery, but for it we often have to wait many months, and it does 
not occur until an alarming general emaciation has set in, attended 
by a gradual decrease of the albumen. The absence of dropsy 
is most readily explained by the fact that in scarlatina both 
kidneys are almost always affected; in diphtheria probably only 
one is implicated, while the other remains in a normal condi- 
tion. 

bronchitis and pneumonia, as complications of diphtheria, will be 
more advantageously spoken of in connection with croup. 

Myocarditis, molecular degeneration of the cardiac muscle, is a 
tolerably regular pathological condition found in cases of sudden 
death, and occurs more or less frequently in every severe epidemic. 

Intestinal catarrh, during and after diphtheria, in small children 
who are still laboring under dentition difficulties, is often of a very 
protracted duration, and, conjointly with the increasing anaemia, fre- 
quently leads to death. 

The diphtheritic joara/yszs is of an extremely peculiar nature ; its 
connection with diphtheria has been pointed out by Orillard only 
within the last decade. As regards the frequency of this phenomenon, 
it is extremely variable in different epidemics. In some epidemics 
almost all convalescents are said to manifest symptoms of paralysis ; 
in others, again, for example in the one I witnessed, but a small num- 
ber were so affected. The time of its occurrence happens mostly in 
the third or fourth week from the invasion of the disease, not often be- 
fore ; sometimes, however, much later, so that its subjects may seem 
to have enjoyed perfect health for from six to eight weeks, and still 
be hable to be attacked by paralysis. It begins almost invariably at 
the palate. The children suddenly get an indistinct snuffling speech, 
as is witnessed in persons with congenital or sjq^hilitic-acquired defect 



92 DISEASES OF CHILDREN. 

of the palate, and the gutturals in particular are pronounced mth ex- 
treme difficulty. At the same time embarrassed deglutition ensues, 
and a part of the swallowed drinks, with or without a spasmodic 
cough, flows out at the nose. In most cases the paralysis remains 
confined to this small space; the general condition of the system, 
with the exception of a remarkable bloodlessness, is not perturbed, 
and the complication usually terminates in sudden recovery after sev- 
eral weeks. The prognosis assumes a far worse aspect when the ex- 
tremities also become paralyzed, and in paralysis of the muscles of the 
body death usually ensues in consequence of the laborious, difficult, 
and imperfect respirations. Paralysis of the extremities occurs more 
frequently in the lower than in the upper, in most instances is bilateral, 
and is in no way to be distinguished from that occurring after typhus 
or scarlet fever. 

Lastly, the diplitheritiG amaurosis is also remarkable. The loss 
of sight is not complete, but consists only in a diminution or weakness 
of vision, smaller objects not being distinctly perceived. Ophthal- 
moscopically, no constant morbid changes can be demonstrated, and 
specialists, according to the precepts of Donder, assume the existence 
of a paralysis of the sphincter iridis, and of the tensor choroideae 
muscles. Tliis evil, as a rule, also disappears completely in a few 
weeks. Relapses of all of these paralytic symptoms have been ob- 
served, but seem to be very rare. 

Pathological Anatomy. — The essential anatomo-pathological con- 
dition seems to be the existence of false membranes, w^hich most fre- 
quently occur on the posterior parts of the mouth, pharynx, and larynx. 
They are usually yellowish white, but in the cadaver, especially where 
the mouth has been open, they soon become darker, brown, or blackish, 
as a result of desiccation. Sometimes they can be removed with 
ease, at other times with difficulty, from the subjacent mucous mem- 
brane, and the latter, as a rule, displays no loss of substance, only a 
diminution of its natural gloss. The microscopic examination of these 
membranes furnishes few important facts. They consist in greater 
part of granules and cells, -sohtary epithelium-cells, and strise of 
fibrine. The morbid changes in the larynx and lungs will be de- 
scribed further on. 

Treatment. — The most varying, totally antagonistic views prevail 
concerning the treatment of diphtheria, from which alone it follows 
that all the remedies hitherto employed are of doubtful efficacy. Since 
the site of the disease is within easy reach of hand and eye, a local 
treatment has always been recommended and persisted in. There is 
no escharotic that has not already been tried in this disease. Of this 
class of agents, nitrate of silver and muriatic acid have acquired the 



DISEASES OF THE DIGESTIVE APPARATUS. 93 

greatest reputation. Of late, some very eminent English physicians 
have abandoned these escharotics altogether, and found that the result 
of their treatment is by no means less favorable ; on the contrary, 
even somewhat better. In view of these considerations, I have for the 
last two years totally abandoned the cauterizing treatment, and by 
hundi'eds of cases convinced myself of the correctness of those state- 
ments. I may declare with a perfectly clear conscience, and to the sat- 
isfaction of the numerous tormented diphtheritic children, that cauter- 
ization with the substances hitherto used has no favorable influence upon 
the local affection. In somewhat older patients, say up to five years of 
age, I prescribe the inhalation of pure lime-water five to six times daily 
for at least five minutes at a time, by the now very simplified pulveri- 
sateur^ and have derived remarkably good results from this mild and 
considerate treatment, to which children of this age may by kindness 
be induced to submit. Internally, for many years past, I have given 
nothmg but chlorate of potassa : to children under one year, 3ss — 3i; 
of one to three years, 3 ss ; of three to five, 3 ij ; to still older ones, 
3 i, in twenty-four hours, dissolved in several ounces of water. 'SYhen 
diarrhoea or great restlessness is present, an appropriate dose of opium 
or morphine may be added with advantage. Carbonate of soda, in 
quantities of 3 i 2:>ro die, praised so much by the French as a specific 
for this disease, has not proved itself as such in this country, and is 
really far inferior in its effects to the chlorate of potassa. When the 
strength begins to fail, the system should be supported by wine, qui- 
nine, camphor, castoreum, etc. For the treatment of diphtheritic croup, 
see further on under diseases of the larynx. 

(9.) Ptjteid Soke Mouth [Sto^nacace). — I have never yet had 
an opportunity to see the commencement of stomacace, and conse- 
quently can neither indorse nor contradict the assertions of authors, 
according to which a catarrhal stomacace is present at first. Stomacace 
that is already fully developed — for only against this is medical assist- 
ance usually sought — is attended by the following symptoms : 

The borders of the gums in some places are yellow, coated with a 
thin layer of yellow mucus and their sharp margins have disappeared, 
owing to which the teeth seem to be a little larger than before. The 
slightest touch on such a gum causes bleeding of the ulcerated places. 
Notwithstanding the slight amount of space involved in the ulcerative 
process, the affection can be recognized at a distance of many inches 
by the sense of smell. Stomaeace always emits a peculiar fetid smell, 
and it is by the aid of this odor that we are able to differentiate it 
with ease and certainty from the higher stage of catarrhal stomatitis, 
where, after the minute vesicles have burst, small, flat, yellow ulcers 
also take place. ^ 



94 DISEASES OF CHILDREN. 

In this, the first degree of stomacace, the mucous membrane of 
the mouth is but slightly swollen, and its secretion not materially 
increased. 

In the second higher grade, the parts lying in contact with the 
gums become immediately infected and undergo the same morbid 
changes as the gums. The mucous membrane of the cheeks swells 
up intensely, so that the impression of the individual teeth is very 
distinctly seen upon it ; so also the mucous membrane of the tongue, 
which upon its upper surface is covered with a white fur, and its bor- 
ders exhibit the dental impressions. PI. III., Fig. 1, represents the 
contour of such a tongue. Also its whole periphery, in consequence of 
the swelling and compression by the upper and lower rows of teeth, 
becomes sharply angular. The same kind of yellow ulcerations now 
form on the cheeks, lips, and tongue, as were originally only present 
upon the gums. The swelling rapidly increases. As a result of this 
the patients are no longer able to shut the mouth, they keep not 
only the lips open but also the jaws, in order to prevent the touch- 
ing and friction of the extremely painful ulcers, and a brownish-red, 
foul-smelling saliva flows down in large quantities over the swollen 
lower lip. Here, too, the cervical glands become painful and swollen 
almost as regularly as in diphtheritic oris. I have never yet observed 
membranes to form upon the ulcers. This disease has but a slight 
tendency to heal spontaneously ; the oedema, the ulceration, and the 
fetor, may remain untreated for months, the teeth then become loose 
and fall out, and the children seriously emaciated. Finally, after a 
long time, spontaneous healing seems to ensue. 

Mastication, deglutition, and speaking, in the more serious form, 
become almost altogether impossible ; the patients will not drink for 
a long time, till the thirst becomes insupportable, and then they 
will consume large quantities of cold water or cold milk at a draught, 
under evident pains. In older children fever does not usually come 
on; the pain, however, at every movement of the mouth, and par- 
ticularly on swallowing, makes them ill-humored in the highest 
degree. 

The etiology is a manifold one. The contagiousness of the dis- 
ease may be very clearly and explicitly demonstrated. Some of the 
children of a family or neighbors upon the school-benches very readily 
impart it to the rest. A stage of incubation, as in the exanthemata, 
does not seem to exist, if at all, but for a very short time ; at any 
rate, I have always noticed it to appear tolerably simultaneously in 
many famih'es. Moreover, it may also originate spontaneously in chil- 
dren as in adults, for which carious teeth are the predisposmg agents ; 
and, finally, there is a disease of the mouth in small children, produced 



DISEASES OF THE DIGESTIVE APPARATUS. 95 

bj calomel, whicH can in no way be distinguished from the stomacace 
just described ; it is then that the absence of the properties of infec- 
tion of the so-called stomatitis mercurialis becomes valuable as a dif- 
ferential sign. 

Diseases of the mucous membrane of the mouth, caused by mer- 
cury, occur in children less frequently and much later than in adults. 
I have never yet seen stomacace to supervene as a result of the ex- 
ternal application of mercury in the form of blue ointment, although 
I have used it for the last three years in all syphilitic children, when- 
ever the state of the skin allowed. In small children, salivation is 
an extremely rare phenomenon. 

Treatment. — We are so fortunate as to possess but one remedy 
for stomacace, and that is chlorate of potassa^ Jcali chloriciim. To 
children under one year of age, I give 3j daily; under two years, 
3ss; under three, 3ij: children who have attained the fourth year 
tolerate very well 3 j i>?'0 die. The various quantities are always 
dissolved in four ounces of water, sweetened with a little syrup, and 
administered in from twelve to eighteen hours. After the end of 
this time, the smell, in all cases and in every degree of stomacace, is 
completely ahoUshed. In cases of less extensive ulceration, a recovery 
instantly takes place, the gums become firm, the yellow border is cast 
off, touching with the finger no longer causes bleeding, and the pa- 
tients are again able to masticate and speak without pain. Even in 
the more severe form, the use of chlorate of potassa for one day will 
suffice to annihilate the odor completely, but, if the remedy is not 
continued for three or four days, it will return, and the disease pro- 
gress anew. I have never yet employed this remedy longer than 
four days in any one case, and have never been able to perceive 
from it any bad effects, such as diarrhoea, loss of appetite, ab- 
dominal pains, renal troubles, etc., notwithstanding the hundreds 
of times that I have employed it, and therefore have not prevailed 
upon myself to use it as gargle, instead of administering it inter- 
nally, especially since small children are such poor adepts at gargling, 
and even the larger ones can only with difficulty be induced to do 
it. It is entirely unnecessary to cauterize the ulcers on the cheeks 
and gums which are devoid of smell, and are no longer painful, for 
the cure progresses extremely rapidly without it. Formerly it was 
supposed to be necessary to extract all the carious teeth, of which a 
number are often found in children, before the commencement of the 
second dentition, in order that a cure might take place. It is, how- 
ever, entirely unnecessary, and even directly injurious, for the lacer- 
ated borders of the gums in the vicinity of the extracted teeth im- 
mediately become affected by the stomacace, and the pain and sup- 



96 DISEASES OF CHILDREN. 

purating surfaces are thereby only increased. Alocal treatment, be- 
sides the internal administration of chlorate of potassa, is altogether 
superfluous. 

(10.) SCOEBUTIC IxrLAM:iIATIOX OF THE MuCOUS MeMBEAI^E OF 

THE Mouth. — By scorbutus we understand a diffused disease of the cap- 
illaries, which burst at various j^laces, and, according to the extent of 
the solutions of continuity, allow larger or smaller quantities of blood 
to be extravasated into the surrounding textures. ^Tiether the chemi- 
cal quality of the blood is at fault here is not ascertainable ; this 
much, however, is known, the fibrine of the scorbutic blood coagulates 
slower than that of the normal. 

Now, these hemorrhages in the mouth take place in such a char- 
acteristic manner, that the existence and degree of the scorbutus may 
be inferred from them alone. 

I can only make some allusions to the land-scurvy from my own 
experience ; how children are affected by the sea-scurvy is beyond my 
means of determining. A healthy, well-nourished child, in a good 
dwelling, never becomes scorbutic. Among the more affluent classes 
it is only seen as a sequela of severe, protracted diseases, especially 
tj^hus abdominalis ; among the poorer classes, whole families become 
scorbutic from living in damp houses and existing upon poor and in- 
sufficient food. 

Symptoms. — Paleness, loss of flesh, sadness, or a protracted typhus 
fever, usually precedes, for a long time, the breaking out of the scor- 
butus. Then the gums begin to be painful on mastication, and are 
greatly inclined to bleed. The external border of the gums hes no 
longer in close contact with the teeth ; it is somewhat swollen and of 
a bluish-red color, and at some places abrasions of the mucous mem- 
brane are seen. 

The rest of the mucous membrane on the hard palate and cheeks 
is not affected by catarrhal stomatitis — it is only pale and anaemic. 
Here also the fetor of the mouth is tolerably intense, nevertheless 
it can be distinctly distinguished from that of stomacace. 

When the process lasts for a long period, the entire border of the 
gum will present the apjDearance of a single, bluish-red extuberation, 
covered with small excrescences, and bleed at the slightest touch. 
The teeth are coated with a yellow mucus ; a bro^vnish, fetid saliva 
flows from the mouth ; large and small ecchymoses now apj^ear 
upon the mucous membrane of the tongue, cheeks, and lips ; at 
some places they are absorbed, at others however, they become 
ruptured, and then display fungous ulcers with readily-bleeding 
bases. Under favorable circumstances all these morbid lesions pass 
through a retrograde metamorphosis, though only xerj slowly, it is 



DISEASES OF THE DIGESTIVE APPARATUS. 97 

true, and the gums retain tlieir disposition to bleed for a long time. 
But if the unfavorable causes continue, then all the scorbutic symp- 
toms become aggravated, the teeth fall out, whole pieces of the gums 
are cast off, the ecchjmotic lower extremities become oedematous, 
general dropsy supervenes, and the children perish with anaemia. 

Therapeutics. — The treatment of idiopathic scurvy, that has origi- 
nated through impoverished circumstances only, is very simple, if it 
is possible to improve these conditions ; that is, to put these 
children in a dry, well-ventilated room, and to procure for them clean- 
liness, care, and good attention, and in part animal food. In the con- 
trary case, all the highly-eulogized remedies will fail us. True, 
recoveries also occur here, especially in the warm seasons of the year, 
when the patients are at least able to enjoy the fresh air on the 
streets. Lemon-juice, or some kind of vegetable acid, is everywhere 
recommended as the most useful remedy. The affection of the 
mouth is readily subjugated by astringent gargles, composed of alum, 
tannin, rhatania, catechu, etc., to which a few drops of the tincture of 
mjTrh may be added with advantage. Profuse haemorrhage must be 
arrested by liq. ferri sesquichlor., or by cauterization with lunar 
caustic or concentrated muriatic acid. When gangrenous destruction 
sets in, the powers of the system should be supported by wine, 
quinine, tonics, and good diet. Scorbutus, after typhus fever, is one 
of the most disagreeable complications of that disease. Owing to the 
great prostration of the functions of absorption, all methods of nourish- 
ment, as a rule, prove futile. 

(11.) Noma (from vo/^jy, corroding ulcer). — By noma, cancer aquat- 
icus (Wasserkrebs), gangrsena oris, stomato-necrosis, a gangrene of 
the cheeks is understood, which makes its appearance under such 
constant and peculiar phenomena that it demands a separate descrip- 
tion and classification as a special kind of gangrene. The older 
writers on medicine do not seem to have been acquainted with it ; the 
first work upon this subject is by JBattus^ a Dutch physician, at the 
commencement of the seventeenth century. 

Noma occurs almost invariably in children between the ages of 
two and twelve years. Nurslings seem to be entirely exempt from it. 
Adults, too, are but extremely rarely attacked by it ; many physicians 
have never seen it in the latter. A protracted febrile disease, scarlatina, 
measles, or typhus fever, always precedes the noma, and no instance is 
known of a previously perfectly healthy child becoming affected by it. 
It does not occur in an epidemic form ; it is asserted that it never 
appears in the southern countries ; it seems most frequently to prevail 
in Holland; girls are oftener attacked by it than boys, and almost 
always only one-half of the face is implicated. 
7 



98 DISEASES OF CHILDREN. 

Symptoms. — Noma is always situated in the cheek, and most fre- 
quently on that part thereof lying adjacent to the angle of the mouth. 
I have only once seen an acute gangrene originate in the deeper 
structures beneath the lobe of the ear, which, like the ordinary noma, 
quickly spread through the deeper structures of the parotid, and later- 
ally over the cheek, neck, and lobe of the ear, and in a few days 
brought about a lethal end. Usually, a child convalescing in the very 
best manner presents a tolerably distinct, circumscribed, indurated spot 
on the cheek near the angle of the mouth, which causes no very great 
amount of pain. On inspecting the mouth, a serous vesicle is seen 
only exce]3tionally opposite the induration; usually it is ruptured, 
and the mucous membrane has undergone a brownish-black, shreddy 
decomposition. 

The cheek swells up, and the adjacent glands of the neck become 
infiltrated. The integument of the cheek is pale, waxy, and glisten- 
ing, and the portion covering the place of the first induration, oppo- 
site to the internal disorganization, turns blue, the epidermis becomes 
flaccid, is detached with the utmost ease, or falls off of its own accord, 
and now it is seen that the gangrene, progressing from within out- 
ward, has reached the skin. At first, the gangrenous part of the cheek 
is barely of the size of a nickel penny, and contracts by desiccation, 
then a brownish-red furrow forms between the living and mortified 
skin, and this furrow extends peripherally more and more, so that the 
gangrenous part may be seen to increase in circumference from hour 
to hour. The gangrene extends further and further, till in some cases 
the entire cheek up to the eye, to the ear, and to the cervical region, 
has become involved, and the patient presents a disgusting picture of 
horribly-destructive disease. The noma does not merely extend exter- 
nally, but it also attacks the bones of the jaws ; the upper (sometimes 
also the lower) maxilla rapidly becomes necrotic, the teeth fall out, and 
after a few days the necrosis is so complete that large pieces of bone 
may be removed Avith the dressing-forceps. A fetid sero-sanguinolent 
ichor flows from the irregular, ulcerated, sloughing surface, wliich is 
but little sensitive. The borders of the sound parts are reddened, 
several serous vesicles sometimes form upon the apparently still 
healthy cheek, at a distance of a few lines from the gangrenous spot, 
the subjacent tissues rapidly mortify, and the borders of the new and 
of the old ulcers approximate each other closer and closer, till they 
finally form one large gangrenous, phagedenic surface. On examin- 
ing this mortified part, a large quantity of free fat will be found mixed 
with traces of muscle, the nerves are yellowish white, and the blood- 
vessels are filled with thrombi. The thrombi seem to have formed 
very early in the disease, and in a very severe degree ; for h^emor- 



DISEASES OF THE DIGESTIVE APPARATUS. 99 

rhages are extraordinarily rare occurrences here. This intensely de- 
structire process runs its course in from three to six days. 

The general phenomena and fever are, at first, insignificant, and 
appear only as consequences of the local destruction and purulent 
absorption ; soon, however, diarrhoea of a colliquative nature comes 
on, syncope, sojDor, or dehrium, becomes superadded, and the feet, as 
a finale, become oedematous. At the autopsy, we generally find, in 
addition, lobular pneumonia, which, during life, on account of the ex- 
treme prostration of the whole organism, manifested but few objec- 
tive and subjective symptoms. Noma is easily diagnosticated. It is 
difi'erentiated from all other kinds of stomatitis by the rapidity with 
which the external structures become involved, and the rapid spread- 
ing of the gangrene. The prognosis is very bad. Out of five cases 
that came under my observation, one only recovered, and that, too, 
with a frightfully-disfigured nose and cheek, which were only partly 
remedied by several plastic operations, but not without great distor- 
tion of the adjacent parts. According to a compilation by Toiirdes, 
sixty-three out of two hundred and thirty-eight cases recovered. 

Treatment. — Chlorate of potassa may also be given in this disease, 
with the object of ameliorating the fetor, in the same manner as rec- 
ommended in stomacace. Here, however, the efi'ects of this remedy 
are not so brilhant ; the gangrene keeps on progressing, and the odor 
is but slightly diminished. In order to abate it as much as possible, 
it is necessary to bathe the children daily, and to change their gar- 
ments often, because they constantly wipe their ichorous, soiled 
hands upon them. An attempt must be made to arrest the progress 
of the gangTene by cauterizing the healthy parts contiguous to it. 
Concentrated muriatic acid, with which the whole border of the 
noma, internally and externally, should be pencilled over two or three 
times daily, seems to be the most appropriate escharotic. The child 
should be firmly held by an assistant, for the pain is very severe, and 
all the superfluous acid on the surface of the mucous membrane of the 
noma should be wiped away with a small sponge. In this manner it 
is possible, in some cases, to keep the evil within bounds. In most 
cases, however, the gangrene progresses unrestrained, and the patients 
perish in from two to fourteen days with the above-described symp- 
toms. Not much can be accomplished mth a stimulating treatment 
of wine, decoct, cinchonas, eggs, etc., for usually it is impossible to in- 
duce them to partake of such nutriments ; milk or coffee is about the 
only article of diet for which they have any relish, of which as much 
as possible should be administered to them. 

(12.) Thrush. — By thrush, sprue, soor (Mehlmund, Mundsohr), 
muguet, blanchet, of the French, aphthae, stomatitis cremosa, aph- 



100 DISEASES OF CHILDREN. 

thophyta, by all these different designations only one process is 
understood, namely, the formation of white membranes in the mouth, 
which, microscopically, consist (1.) Of a granular mass, (2.) Of base- 
ment epithehum, and (3.) Of fungi in their various stages of develop- 
ment. (PI. in., Fig. 2.) B^obin has called this fungus oidium 
albicans. The views of the different authors on the nature of this dis- 
ease vary in many respects, at the present day, although it occurs 
extremely often, and almost daily presents itself for examination to 
every physician, and although the mouth is accessible to all the senses. 

Thrush attacks, by preference, infants in the first months of life, 
but in some instances it has also been observed in children one or 
more years old; in addition, also, in cachectic adult individuals, and 
especially tuberculous and carcinomatous patients. 

Symptoms. — At first the natural bright-red color of the mouth 
becomes altered, a livid, dark-red color takes its place ; the entire 
mucous membrane appears as if a thick layer of raspberry syrup had 
been smeared upon it. This change of color never occurs in the 
form of spots or islands^ but is uniformly diffused over the entire 
cavity of the m.outh. Only on the hard palate, where the mucous 
membrane is firmly adherent to the bone, and on the border of the 
lower jaw, where the teeth which are near breaking through cause a 
marked tension and attenuation of the super-lying mucous membrane, 
no such decided dilatation of the capillaries can take place, and it is 
on that account that the redness is less developed there ; sometimes 
there is a marked contrast between the entire yellowish-red hard 
palate and the rest of the livid-red mucous membrane. The tongue 
is darkest in color, and its papillse, particularly those at its margins, 
are a little more prominent than usual. The temperature of the 
mouth, according to the sense of touch, is slightly increased ; no 
exact thermometric measurements can be obtained in children. The 
mouth, at the same time, becomes painful to the touch, as is apparent 
from the efforts of the infants to expel every foreign body introduced 
into it. In the normal state, for example, when a finger is introduced 
into the mouth, they instantly begin to suck at it ; but, when affected 
with this disease, they wiU try to remove it by rolling the head from 
side to side, and will also begin to cry. For the same reason they 
often stop during nursing, and rest for a while, from the pain to the 
inflamed mucous membrane, caused by swallowing. 

Further on in the disease an anomaly in the secretion of the 
mouth takes place. The mucous membrane loses its lubricity, feels 
tenacious, and a piece of filtering paper laid upon it sticks to it ; in 
the normal condition, the filtering-paper does not readily adhere to it. 
The distinctly acid reaction of the secretion of the mouth, at a time 



DISEASES OF THE DIGESTIVE APPARATUS. IQl 

when as jet none but these changes of the mucous membrane can 
be perceived, is of the highest importance, and supplies an index in 
judging of the entire morbid process. 

In the mouth Tve have a mixture of two glandular secretions, 
namely, the secretion of the salivary glands and of the mucous folli- 
cles. Pure salivary glandular secretion always reacts alkaline, and, 
indeed, most distinctly so, immediately after a meal. The secretion 
of the mucous follicles very soon becomes sour, and this acid reaction 
is always more distinct when the fresh mucus is allowed to stand, for, 
owing to the fermentation that takes place, free acid is rapidly 
generated. We have, then, two diametrically opposite reacting 
fluids in the mouth, and it will depend upon their quantitative rela- 
tion to each other, and their degrees of concentration, whether the 
mixture should possess more of the properties of saliva or of mucus. 
If a sufficient quantity of alkaline saliva is present, the free acid de- 
veloping in the mucus is thereby neutralized; if not, a distinctly 
acid-reacting secretion of the mouth originates. 

The tenacious, highly-red mucous membrane, at the commencement 
of thrush, always reacts acid, even if it has been cleansed in water 
and not been in contact with any food for a whole hour. If any mucous 
membrane so constituted is scraped off, and the raspings examined 
by the microscope, the)'e is founds conjointly loith the epithelium^ a 
considerable quantity of oval, sharply-defined bodies, sometimes con- 
nected together in ticos or threes, which are easily recognized as 
fungous spores. True, a highly-red, acid-reacting mucous mem- 
brane is also met with, where it is not possible to detect upon it 
any of these spores ; I have, however, never succeeded in discovering 
them upon a normal, pale-red mucous membrane that had been well 
cleansed in water, and had not been in contact with any food after- 
ward. From this it follows that the disease of the mucous mem- 
brane primarily originates without the formation of fungi, and 
that no fungi ever form upon normal mucous membrane. These 
fungi do not produce the acid reaction and redness, but the chem- 
ically-altered glandular secretions accumulate in the mouth, irritate 
the mucous membrane, redden it, make it hot and painful, and 
transform it into a soil favorable for the extuberations of the fungi. 
The crj^togamous growth makes as rapid progress in the mouth as 
upon any foul, vegetating surface, only with this difference, that here 
the soil does not become altered again, whereas, there it belongs to 
a living organism, and therefore never stops for a moment to regen- 
erate itself from below, and from becoming cast off on the upper 
surface. 

On inspecting the mouth, small white points will be seen, if the 



102 DISEASES OF CHILDREN. 

cryptogamous gro^^'tlis have only existed for a few hours ; they soon 
become confluent at some places, form large patches, and often cover 
the entire mucous membrane with a thick white scab, which, on 
drying, turns yellowish from contact with the air, and may even 
become brown through an admixture of blood. Much difference 
of oi^inion has existed hitherto regarding these membranes ; the man- 
ner of their adhesion to the mucous membrane, their relation to the 
epithelium, and the place of their primitive appearance, have been 
much disputed. 

First of all, as regards their connection with the mucous mem- 
brane itself, it is claimed by some that they may be detached fi^om 
the subjacent mucous membrane without producing any heemor- 
rhage ; others deny this ; both, however, are right. It all depends 
upon the time after their origin that the attempt is made to detach 
them. Shortly after their appearance they are really very firmly con- 
nected, and cannot be detached, even by an experienced hand, with- 
out inducing haemorrhage ; but, after a few days, they become loose, 
and the mothers will easily remove large patches with the finger 
without causing pain or heemorrhage. 

In order to answer the question in reference to the epithelium, I 
must, in the first place, review more minutely the microscopic condi- 
tion of these membranes. There are seen, in every thrush-membrane, 
s2:)ores, spore-hearers^ thallus filaments^ and basement epithelium^ all 
surrounded and enveloped in a white, finely-granidar substance, 
from which, on the borders only, these structures can be made to 
project by squeezing. If successful in detaching a large piece, and 
its surfaces can be distinguished and separately examined, then, on 
the upper surface, mostly spores will be found, fewer thallus fibres, 
and many fully-developed basement epithelium-cells; on the lower 
surface, the one facing the mucous membrane, less or no basement 
epithelium-cells at all, fewer spores, but a dense structure of thallus 
fibres, which permeates throughout the whole finely-granular mass. 
If a 23iece of thrush-membrane is kept for a day in a concentrated 
solution of carbonate of potassa, its epithelium will be the first to 
disappear ; the white gTanular mass becomes more homogeneous, 
more transparent, and is recognizable at some places only ; the 
thallus fibres, however, the dense structure of which may now readily 
be discerned throughout the whole thickness of the membrane, have 
undergone no change. 

On some of the yellow places of the membranes a diffused color- 
ing matter is seen, dyeing the finely-granular mass yellow ; it is in- 
debted, for its origin, to small haemorrhages. Two kinds of thallus 
fibres may be distinguished : 



DISEASES OF THE DIGESTIVE APPAKATUS. 103 

(1.) Broad with transverse stride, very much after the manner of 
yeast fungi ; and (2.) Narrow, with scarcely any stride. The latter have 
no well-defined contours, are slightly granular, and are seen every- 
where and in all cases, whereas the first kind is only exception- 
ally found. These spores flourish not only in the mouth, but grow 
also on other moist fermenting surfaces, upon a slice of an apple, 
for instance, as I have illustrated by experiments. {Senle and 
Pfeufer's Ztschrft. N. F. VIII. 2. Heft.) Erosions upon the exter- 
nal part of the lip, and even the anus, may become covered with it. 

From aU that has been said, the origin of the white membranes, 
and the relation of the fungi to them, may be regarded in the follow- 
ing manner : The first thallus filaments grow upon and between the 
uppermost epithelial layer ; seek everywhere, like the roots of a tree 
on stony soil, for favorable space and ground, and finally lock in the 
entire epithelial strata, in a densely-fungous texture. Having reached 
the upper, the epithelial surface of the mucous membrane, they 
stimulate it to increased secretion, or, at least, aggravate the irri- 
tation caused by the acid reaction of the fluids of the mouth, and, 
henceforth, no complete epithelium-cells are formed from the blastema 
secreted for the formation of epithelium, but only a thick layer of 
granular substance. The fungi are therefore neither upon the epi- 
thelia, nor beneath them, but enclose them everywhere ; within 
the layers facing the mucous membrane, it no longer attains to the 
formation of complete basement epithelium, the thallus fibres, like 
the granular mass, seize upon them, and permeate them in every 
direction. 

As regards the primary place of origin, many authors assert 
that the primary white points represent mucous follicles, and that the 
fungi sprout from these. This statement can neither be confirmed 
nor denied, because it is well known that in the living child the ori- 
fices of these glands cannot be distinguished, and in the cadaver the 
presence of these thallus fibres in the follicles is no proof that they 
have actually originated there before they originated upon the free 
surface of the mucous membrane. 

As regards the spreading of thrush, Heuhold found that the fungi 
adhere to the pavement epithelium, and do not thrive upon the cil- 
iated and cylindrical epithelium ; consequently the parts subject to it 
are the mouth, fauces, oesophagus, and the epiglottis, down to the 
superior chordse vocales, by which the hoarseness which occasionally 
supervenes is readily explained. The tolerably wide-sj^read view en- 
tertained by older physicians, that thrush may extend down into the 
stomach and intestinal canal, has never yet been confirmed by dis- 
section. Although the possibility of thrush-membranes having been 



104 DISEASES OF CHILDREN. 

swallowed, and subsequently passing off by the anus in an undigested 
condition, cannot be denied, it nevertheless does not follow therefrom 
that they had originated in the stomach and intestines. 

The duration of thrush, as a rule, is a short one, and in cleanly- 
kept and well-developed children very rarely lasts beyond the eighth 
day. In atrophic children, particularly when their incessant restless- 
ness is appeased by the sucking-rag, it will last for many months, or 
until death. 

This affection of the mouth, especially in foundling and lying-in 
houses, is extraordinarily frequently complicated with intestinal catarrh 
of the most malignant character. This complication is so common 
that Valleix, physician to the Foundling-house at Paris, regards the 
intestinal affection as an integral part of the disease, and describes 
it as such; but that is sufficiently contradicted by observations in 
private practice. 

Children are attacked by cholera-like symptoms, become collapsed, 
the anterior fontanel becomes depressed, the eyes sink back deeply 
in their orbital cavities, the integument loses its elasticity and 
warmth, and, in from twelve to twenty-four hours, often become 
remarkably emaciated. The green, watery faeces, smelling strongly 
of rancid, sour fat, react decidedly acid ; redden and erode in a short 
time the anus, genitals, the inner surfaces of the thighs, and the 
heels. That this diarrhoea, or rather its effects, and not the affection 
of the mouth, may lead to death, follows from this, that some chil- 
dren, with very severe thrush, suffer from no intestinal catarrh, and 
are perfectly well again immediately after the membranes have been 
cast off. 

The causes of thrush are, then : (1.) The preponderating acid re- 
action of the mouth, which in the new-born is due to a faulty salivary 
secretion. The quantity of the acid mucus outweighs the alkaline 
saliva, and then the mixture reacts acid. (2.) The transportation 
from one child to another, particularly through one and the same wet- 
nurse in foundling-houses. (3.) The almost unexceptionally ferment- 
ing substances of the sucking-rag, which is sometimes allowed to lay 
about upon all dirty tables and places, and afterward is thrust into 
the mouth of the infant. 

Therapeutics. — From a large number of experiments that I have in- 
stituted in this direction, I have come to the conclusion that a thrush- 
membrane, when kept in sugar or well-water, and in a not-alkaline 
reacting solution of salt, at a temperature of about 110° F., w^ll, 
at the expiration of two days, produce a new crop of fungi, whereas in 
solutions of alkaline or metallic salts this does not take place. Thrush- 
membranes are effectually dissolved in concentrated solutions of caustic 



DISEASES OF THE DIGESTIVE APPARATUS. 105 

alkali only, wliicli, of course, cannot be resorted to for therapeutic pur- 
poses. We have, therefore, no useful remedy that will chemically 
destroy the membranes in the mouth when once formed, but we can 
easily prevent their further spreading by topical applications of salts, 
with slight alkaline reaction. The whole treatment is based upon 
this : to rectify the acid reaction of the mouth, and this purpose is 
completely achieved by a solution of borax, 3 j, to water, § j? applied 
mth a small camel's-hair brush every hour. The good effects of this 
remedy, however, are often completely thwarted by the unnecessary 
admixture of honey or S}Tup, for all substances which contain sugar 
very decidedly promote the grow^th of the fungi. By this solution 
of borax no diarrhoea is produced, nor is an already-existing one ag- 
gravated. It is absolutely necessary to discard the sucking-rag ; even 
a milk-diet is injurious, on account of its containing sugar and casein. 
So long as the membranes exist it is best to feed the child upon 
bouillon and mucilaginous broths, and infus. verbasc, with little or 
no sugar at all. 

APPENDIX. 

(a.) The Signification of a Coated Tongue in Childeen. — 
It is necessary, first of all, to state that most nurslings in the first 
weeks of Hfe have a white-coated tongue, along with which they do 
not display the least digestive disturbance. 

Aside from that, the tongue becomes coated in most of the gastric 
and intestinal affections of small children, and probably only in con- 
sequence thereof does the appetite decrease. A thickly-furred tongue 
is but seldom met with in children ; as a rule, a white flush only is 
observed, but this may exist for a long time after the appetite has 
returned, and may just as well be produced by local diseases of the 
mouth, thrush, stomatitis catarrhalis, diphtheria, injuries, chemical irri- 
tants, and burns, as by disease of the stomach or bowels. There are 
also permanent, or at least of several months' duration, partially- 
coated tongues, which possess no influence whatever upon the con- 
tinuation of good health. A special name has even been invented 
for this condition, ^^zYyrmszs U7iguoe. It consists of white islands, or cir- 
cles or semicircles, the rest of the tongue being of a normal rose-red 
tint ; these spots are entirely indebted for their origin to an accumula- 
tion of epitheHum-cells. In atrophic children, transverse fissures are 
often seen upon a very smooth red tongue ; the fissures display yel- 
low* bases, obstinately resist the cauterizing treatment, and do not dis- 
appear before death. The furred tongue of measles, scarlatina, typhus 
fever, etc., has the same significance in older childi'en as in adults, 
and will be specially described with every individual affection. 



106 DISEASES OF CHILDREN. 

The diag]iostic and practical importance of the coatings of the 
tongue in children is, on the whole, not particularly great. In a 
uniform, although but a very thin, coating of the tongue, it is al- 
ways advisable to be careful with the diet of the children, and, by regu- 
lating it, the digestion will improve, and the tongue Avill become 
clean. 

(b.) DrFFicuLT Dextitio^^ (De7itiiio Difficilis). — As the physi- 
ological condition of the eruption of the teeth has already been 
minutely treated of in the Introductory Remarks, it only remains 
to speak of the pathological conditions which originate during that 
process, and are decidedly dependent upon it. 

Redness, pain, swelling, and increased secretion (or, in short, catar- 
rhal stomatitis), are present in all cases. The frequent formation of blis- 
ters and small painful ulcers may be regarded as an aggravation of 
that process, and should be treated according to the precepts laid down 
on page 87 (Stomat. eatar.). The necessity of the children to bite 
at something is satisfied by a piece of yew-tree root, or by a thimble 
firmly stuck upon the finger. 

As ordinary or sympathetic results of the eruption of the teeth, 
the following make themselves manifest : 

(1.) Fever ^ consisting in an increased temperature of the skin, 
especially on the forehead and cheeks, one of which often becomes 
red. Since no other cause for the fever can be discovered in the 
children, and as it nevertheless frequently occurs in dentition, it must 
therefore be assumed that it is induced by the latter. 

(2.) Convulsions — the so-called spasms {Fraisen). The convul- 
sions which occur here have nothing characteristic whatever, and are of 
the same nature as symptomatic convulsions in general. The most 
frequent muscular contractions are those of the eye ; teething children 
often sleep with half-closed eyes, the eye-bulbs rolled upward, and 
nothing but white sclerotica can be seen through the tolerably wide- 
open palpebral fissure, a phenomenon so terrifying to the inexperienced 
parents, that medical aid is usually quickly sought. Twitchings 
of the facial muscles, a peculiar smile while sleeping, and short 
twitchings of the extremities, are observed in many teething chil- 
dren, who are extremely nervous, and attacked by reflex convulsions 
from the least indisposition — even from emotional causes. Since they 
make their appearance in many children every time a tooth breaks 
through, there is no reason why they should not be regarded as 
having direct connection with the dentition. Still, eclamptic at- 
tacks occur in some children with and without dentition, which may 
destroy them in a few minutes ; and at the autopsy no material lesion 
whatever of the nervous centres can be discovered. 



DISEASES OF THE DIGESTIVE APPARATUS. 107 

Treatment. — As these con\ailsions mainly occur in children with 
sluggish digestion and hard stools, and disappear when diarrhoea su- 
pervenes, the first indication must therefore be to increase the intestinal 
secretions and to accelerate the peristaltic movement of the bowels. 
A clyster or two of cold water should be administered to them, and, 
if this does not answer, a little manna, or a few teaspoonfuls of 
5. rhei aquosa. But, if a hot skin is also present, it will be necessary 
to produce more frequent stools, and a diminution of the tempera- 
ture, which may be accomplished by a few powders of calomel, gr. -J 
to ^ each. Much eclat has lately been made in England and France 
with the scarification of the gums. Some recommend a crucial incis- 
ion ; others, the removal of the whole cap which covers the head of 
the tooth. But, as an admonition, it is premised, in all the reports and 
laudation, that the tooth has to be very near eruption, otherwise the 
scarification will be of no benefit. I have frequently performed this 
operation, but have always found that the lancinated wounds of an in- 
flamed mucous membrane heal very badly, and ulcerate for a long 
time ; that the nervous symptoms continue notwithstanding, till ulti- 
mately artificial or spontaneous diarrhoea supervenes. Indeed, if we 
have to wait until the tooth is "very near " breaking through, then the 
process is in fact near its end, and any other simple remedy is as effi- 
cacious as this, which is attended by a considerable amount of pain. 
Afiiisions of the head with cold water, performed every hour or two, 
are, it is true, a not very tender, and by parents not much admired, 
remedy ; it is, however, very useful against all convulsions in children, 
and therefore also against those occurring during dentition. 

(3.) Cutaneous Eruptions. — Children with a fine, smooth skin, or 
the progeny of parents who are affected with chronic skin-diseases, 
are attacked in each of the five periods of dentition by one or the 
other form of eruption, which, in the subsequent dentition periods, 
displays tolerably similar pathological characters to those which took 
place at their first appearance. The principal forms are : 

(a) Urticaria. — An eruption of wheals (Quaddeln) (Pomphi). — By 
this we understand a severely-itching eruption of the skin, of several 
fines in circumference and mostly round, or sometimes of an oblong 
shape, not very prominent, and having a flattened upper surface. 
Most of the wheal-like eruptions are of the normal integumentary 
color, while the part of the cutis contiguous to them appears to be 
reddened. Occasionally they are even paler than the rest of the skin ; 
the epidermis never becomes detached from the cutis. The stings of 
nettles (hence nettle-rash), in some persons also the bites of fleas, will 
produce a wheal-like eruption, which differs in no respect from that 
produced by internal causes — dentition, for example. It disappears 



108 DISEASES OF CHILDREN. 

almost entirely in a few hours, the red zone remains for a short time, 
but that also fades very rapidly, and then nothing is to be seen of 
the eruption. From fifteen to twenty of these circular patches make 
their appearance, either simultaneously or one after the other, disap- 
pear, and are succeeded by others on other parts of the body. Gener- 
ally, this afi'ection of the skin is relieved only after the completion of 
a dentition period, and breaks out anew at the beginning of the next 
period. The treatment should be limited to the use of bran-baths, and 
inunction of fat, to mitigate the excessive itching, which is very trouble- 
some and annoying. 

(b.) Lichen and Prurigo, — These are two papular exanthema; 
the first, also called lichen strophulus, has its hard papules mostly 
accumulated in clusters, while the papules of the latter are flatter, 
lower, and isolated. In both exanthema the tubercles are at first 
paler than the normal skin, but through scratching are soon bereft of 
their apices, and in place thereof display a small brown crust of the 
size of a pin's head. If a lichen papule is pricked open very super- 
ficially with a fine needle, a drop of blood will exude ; a prurigo papule 
contains only a minute drop of serous fluid, but, by severe scratching, 
may also be made to bleed. When these scratched papules are situ- 
ated near each other, their crusts will coalesce, and present a large 
ulcerated surface, and it will then be entirely impossible to recognize 
the primary manner of "their origin. 

(c.) Eczema and Impetigo. — By eczema, we understand an inflam- 
mation of the skin, produced by an accumulation of serum beneath the 
epidermis, in the form of minute aggregated vesicles, and is distin- 
guished as eczema simplex and eczema rubrum. In eczema simplex 
the skin is but slightly swollen and reddened. Thin yellow scales 
form after the vesicles have burst and dried up, and, after they have 
fallen ofi", a new epidermic layer is produced. Eczema rubrum mostly 
develops from the former, and is differentiated from it by the in- 
tegument around the vesicles being of a darker red color and more 
tumefied, and the course of the disease becoming more chronic. There 
is a tendency to form a new crop of vesicles, and a red, infiltrated fur- 
fnraceous skin remains behind for a long time after the crusts have 
desquamated. In impetigo, in place of vesicles, larger pustules, filled 
with matter, usually aggregated, originate, and, after they have rup- 
tured, thick moist, yello"^vish-green or bro^vn scales form, and, when 
these have dropped off, the reddened corium will be seen exposed, dis- 
charging a sero-purulent fluid, and soon becomes covered anew by a 
thick crust. The affected part of the skin remains brownish red and 
infiltrated for a long period after recovery has taken place. 

The forms of skin-disease mentioned in paragraphs h. and c. natu- 



DISEASES OF THE DIGESTIVE APPARATUS. 109 

rally do not disappear immediately after the eruption of the teeth ; 
they improve very much, however, while previous to that they con- 
stantly grew worse. It is not yet conclusively settled that the}^ are 
always connected with dentition, for there are many children who do 
not acquire these eruptions until after they have cut all their teeth. 
But this much is established, that very many children are attacked 
by these exanthema, most frequently by lichen, at the eruption of the 
first tooth, suffer from it a while, lose it, and at the next new diffi- 
culties of dentition again become affected with it. 

The treatment of these skin-diseases is extremely simple. The 
hairs should be carefully removed, if any eruption exists beneath them. 
Thick crusts must be softened with oil, and the hairs cut off at the roots 
beneath the crusts. I have found the ung. zinci oxid., rubbed in twice 
daily, to be very efficacious against the intense itching. So long as the 
patients are free from fever, they should be bathed in a tepid bath 
of wheat-bran for a quarter of an hour daily. There is no very 
great indication here for internal remedies, and those which derange 
the digestion should be avoided. In eczema rubrum, which often 
lasts very long, the liq. potas. arsenicalis, from two to five drops daily, 
may become necessary, in regard to the use of which, more minute 
details will be given in the chapter on the Diseases of the Skin. It 
is always advisable to cut off the nails as short as possible, of all 
children suffering from cutaneous eruptions, in order to make the 
scratching as harmless as possible. 

(4.) Intestinal Catarrh. — When a child cutting its teeth has a red 
mouth and augmented salivary secretion, it becomes affected with 
watery evacuations as a result of swallowing the saliva, for the salts 
it contains act as a mild aperient. A mild diarrhoea, five or six evac- 
uations in the twenty-four hours, is very beneficial to teething children, 
for cerebral affections are thereby most surely prevented. It occurs, 
in fact, as often as stomatitis catarrhalis, and both processes might 
very appropriately be regarded as physiological conditions, if their 
aggravations, which often attract attention, did not attain to distinct 
diseases, and really display serious characters. The transition of this 
simple catarrh of the bowels into an infiltratic^ of the follicular ap- 
paratus of the mucous membrane, attended by profuse discharges and 
rapid general emaciation, very frequently occurs, and in most in- 
stances terminates in profound collapse and death. 

The treatment is precisely the same as that of intestinal catarrh 
originating from other causes, and will be described in detail with 
the affections of the bowels. 

(5.) Bronchial Catarrh. — There are children who, at the erup- 
tion of every tooth, are attacked by a severe bronchitis, which dis- 



110 DISEASES OF CHILDREN. 

appears again immediately after the tooth has broken through. This 
bronchitis seems to be induced by external causes. The large quan- 
tity of saliva secreted in stomatitis catarrhalis soaks through the 
clothes, covering the chest, and produces a diminution of the tempera- 
ture of the breast, as a result of which swelling and increased secre- 
tion of the bronchial mucous membrane ensue. If the chest is pre- 
vented from becoming wet, for example, by inserting a piece of oil-silk 
between the garments, the child will pass through the whole process 
of dentition without once being aifected with bronchitis. So many 
striking and oft-recurring examples of this dentition-bronchitis have 
occurred to me, that I do not hesitate to attribute a part of the bron- 
chial catarrhs to dentitio difficilis. 

Treatment. — The treatment consists in protecting the chest, best 
accomplished by employing large-sized slavering-bibs lined with' thin 
gutta-percha cloth or oil-silk ; the cough then almost always disap- 
pears spontaneously in a very short time. 

(6.) Finally, there is a hlennorrhoic affection of the conjimctiva 
palpebrarum^ which occurs at the eruption of the upper cuspid and 
incisor teeth. Here both eyelids, particularly the upper, suddenly 
swell up, and become so infiltrated that it is only with the utmost 
difficulty, and scarcely ever without bleeding from the squeezed 
eyelid, that a sight can be obtained of the globe. The discharge is 
not so yellow and purulently thick as in ophthalmia blennorrhoea 
neonatorum, but more muculent, shreddy, resembling more the dis- 
charge from the nose after a catarrh of the nasal mucous membrane 
has subsided. I have never been able to ascertain whether it pos- 
sesses any properties of infecting the other eye of the same or of 
another person. The parts around the lids are generally eroded. On 
examinino' the mouth of a child laborins; under this form of inflamma- 
tion of the eye, a painful redness and swelling of the corresponding 
upper jaw, and one or two tubercles answering to the first molar or 
incisor-tooth, will be found ; its popular denomination, " eye-tooth," is 
therefore not without sufficient reason. 

After all, this inflammation of the eye has nothing wonderful 
about it, when we bear in mind that the floor of the Highmorrian 
cavity is often barely of the thickness of paper, and consequently a 
propagation of the congestion or inflammation upon the mucous mem- 
brane of this cavity may very readily take place. But the mucous 
membrane of the antrum Highmorri stands in direct communication 
vrith the conjunctiva through the nasal passages and lachrymal sac, 
and we merely have here a propagated inflammation of the mucous 
membrane. The jDrognosis of this seemingly very dangerous e\al is 
favorable. Formerly, in accordance with the precepts of the most 



DISEASES OF THE DIGESTIVE APPARATUS. m 

eminent ophtlialmologists, I used to torture the poor cliildren with 
cauterizations of nitrate of silver, and was delighted with my 
splendid success. But, for several years past, I have treated at least 
a dozen cases with nothing but dry warmth, discarding the cauteriza- 
tions altogether, and have accomplished still more rapid and painless 
cures. I apply a piece of cotton-cloth to the eye, smeared with 
simple cerate or ung. zinci, and over that a bag loosely filled with 
warm bran. I cause the cerate rag to be removed every two hours, 
the eye to be sponged with a pointed piece of soft sponge dipped in 
warm water, and then reapply the warm bran bag as before. After 
one, or at the most two days, the oedema has subsided so much that 
the patients are again able to open the eyes tolerably wide ; then 
they will no longer tolerate the bran bags, and, after several days 
more, there is nothing more to be seen about the affected eye than a 
slight redness and irritability of the lids. If the mouth is now ex- 
amined, the stomatitis will be found improved or wholly gone, and a 
pre^dously unperceived head of a tooth cut through. During and 
after the subsidence of the oedema of the lids, mild astringent eye- 
washes, zinci sulph., or cupri sulph., gr. j, to water ^ j, may be 
dropped into the eye with advantage. 

These are the principal and most frequent complications of denti- 
tion ; their actual dependence upon it has long ago been acknowledged 
by all thoughtful physicians. Of late, however, a few, and some of 
them widely-known Psediatricars, have denied this connection in toto^ 
and either did not observe the frequent concomitance of the just de- 
scribed diseases with dentition, or declared them to be merely acci- 
dental. 

B.—PAR0TI8. 

(1.) iNTLAiniATiox OF THE Pakotid Glai^d {ParotUis). — Tliere 
are three kinds of parotitis : {a) idiopathic, (b) secondary, and (c) 
metastatic parotitis. 

{a.) Idiopathic parotitis occurs only in an epidemic form, and, on 
account of its general spreading, and the almost comical appearance 
which it gives to the patients, has received a number of, in part, scur- 
rilous names, such as mumps, clown's disease, Ziegenpeter, etc. It 
has many analogies to the acute exanthema, attacks a person but 
once in his life, occurs most frequently in the youthful age, and 
has a tolerably well-marked cyclical course. Children under one 
year of age are hardly ever affected with it. It j^revails most fre- 
quently in the spring of the year, sometimes also in the autumn ; and 
on the damp coasts of Holland, England, and France, it is said to 
be endemic. 



112 DISEASES OF CHILDREN. 

Symptoms. — Usually, a few prodromes precede the mumps. For 
one or several days the children feel tired, are ill-humored, fever- 
ish, lose their appetite, and voluntarily betake themselves to bed ; 
indeed, nervous children also manifest cerebral symptoms, head- 
ache, delirium, convulsions ; ravenous children throw up their last 
appetiteless-swallowed meal. After one, at the most two or three 
days, they begin to feel pain under one ear, which becomes markedly 
aggravated on opening the mouth, mastication, or external pressure. 
A swelling is at the same time discovered in the parotid region ; 
first, the depression between the lower jaw and mastoid process 
becomes filled out, and in its place a tumor is found, which pushes 
the lobe of the ear outwardly, and extends beyond the boundaries of 
the gland. The subcutaneous cellular tissue of the corresponding 
cheek up to the lower eyelid, and of the neck, becomes infiltrated 
with serum, so that the movements of the lower jaw and all the mim- 
ical movements of the facial muscles upon the affected side cannot 
be performed. The induration is situated at the place where the 
gland itself lies, is most marked there, and decreases peripherically. 
The external swelling is tolerably soft and doughy; the pressure of 
the finger leaves a pit. The integument covering the tumor is 
slightly inflamed. Frequently only one parotid swells up ; when both 
are affected, they are not usually attacked simultaneously, but one is 
generally a few days after the other; nor is it necessary that both 
should attain to an equal size. At the acme of the disease the 
patients are totally unable to open their mouths, and speak but very 
indistinctly ; the salivary secretion is seldom diminished, often 
somewhat augmented, occasionally profuse ptyalism also occurs, 
but, on account of the absence of ulceration of the mucous membrane 
of the mouth, it does not diffuse the disgusting fetor of mercurial 
salivation. As very rare complications, angina tonsillaris, and 
pharyngitis, may be mentioned. Suffocative attacks very seldom 
occur here, because the swelling extends outwardly and not inwardly. 
In most cases the affection of the general system is of but short 
duration, and slight. So long as the swelling is extensive, hard, and 
painful, it will, in most instances, be attended by fever ; but, by the 
third or fifth day, the local trouble only will be present. The me- 
tastatic swelling of the testis, in adults, frequently that of the same 
side, already observed by Hippocrates, on the whole, occurs ex- 
tremely infrequently : for instance, in the epidemic which prevailed 
in Munich, in 1857, where certainly several hundred men were 
affected, it was seen but once, so far as I am aware ; it is never met 
with in children. 

Nor have I ever yet seen the other metastasias, to the cerebral menin- 



DISEASES OF THE DIGESTIVE APPARATUS. 113 

ges, to the serous sacs, to the bronchial and intestinal mucous mem- 
branes ; still, I do not venture to deny them altogether, for it is well 
known that in some epidemips great variations of the same disease 
may take place at different times. If our followers should witness an 
epidemic of parotitis, to which the description of our contemporaries 
is not exactly applicable, it is to be hoped that they will at least have 
so much consideration as not to regard our present delineation as 
purely inventive. 

Course and Termination. — The course of an epidemic idiopathic 
parotitis is almost unexceptionally favorable. After the affection 
has been growing worse for from two to five days, the fever, and with 
it the swelling, begins to subside, and by the tenth or the fourteenth 
day all the general and local sjnnptoms have disappeared completely. 
Complete resolution of the swelling almost always takes place ; in some 
scrofulous children this is somewhat longer in being accomplished : 
the parotid gland and the lymphatics surrounding it are for some 
time hypertrophied and indurated. Suppurative degeneration of 
the gland does not seem to have been so rare in former epidemics 
as at present. The abscess may burst either directly outward, or into 
the external meatus auditorius, when otorrhoea and hardness of hear- 
ing will remain for a long time, and, in cases where the tympanum 
has been perforated, life-long deafness will be the result. When the 
chronic indurated gland comes to press upon the facial nerve, or if the 
nerve becomes involved in the suppurative process, temporary or 
permanent motoric facial paralysis will ensue. The prognosis, ac- 
cording to what has been said, is extremely favorable. At the be- 
ginning of an epidemic, the physician has an opportunity to see many 
cases of mumps, but, after several weeks, the public become so thor- 
oughly convinced of the utter harmlessness of the evil, that most 
parents seek no medical advice at all. 

Pathological Anatomy. — The pathological anatomy of this disease, 
on account of its being so rarely fatal, is somewhat meagre. I have 
never yet had an opportunity to make a post-mortem examination on 
a case of parotitis epidemica. Bamberger reports as follows in rela- 
tion thereto : The whole gland appears enlarged and reddened, its 
tissues are swollen and flaccid, for primarily a fibrinous exudation of 
various grades is deposited in the interstitial substance that connects 
the acini of the gland with each other, and in the cellular tissue sur- 
rounding the gland. In severer forms, the inflammation attacks also 
the glandular structure itself; this is then found reddened and injected, 
and the entire gland appears to have become hjrpertrophied into a 
uniform, carnified, tough mass. The exudation may now either be 
absorbed again, when the gland will return to its former normal size 



114 DISEASES OF CHILDREX. 

and consistence, or the exudation deposited in the cellular tissue 
becomes solidified and organized, and leads either to a permanent 
increase in size, or to an absorption of the gland, ^Yhen, as a result 
of compression, the proper glandular structure gradually atrophies 
and becomes obliterated. 

Therapeutics. — The treatment of j)arotitis is that of adenitis in 
general. As long as general febrile symptoms are present, rest, strict 
diet, and acidulous drinks, are indicated. The swelling itself is most 
conveniently treated with inunctions of oil. Cold does not in the 
least accelerate the resolution of the swelling. Cataplasms and bran- 
bags are inconvenient and annoying, cause congestion of the head, 
and are but very unwillingly tolerated, especially by small children. 
If the parotitis is attended by very severe pain, and extensive, tense 
swelling, a few leeches will be found useful. Great restlessness is 
soothed by a solution of morphine (gr. ^ to water 3 iij), a teaspoonful 
of which may be given every hour till its effects become apparent. 
Subsequent indurations must be treated by inunctions of mercurial 
ointment. The use of cod-liver oil for several months may prove 
of great benefit, as most children affected with this disease are 
scrofulous. 

[h.) Seco7idary 2yci^'oUtis is a very rare disease, and arises from pro- 
tracted affections of the deeper structures of the mouth. The prin- 
cipal causes of secondary parotitis are mercurial sahvation, diphtheria, 
or a neglected stomacace. It never attains the size, extent, and hard- 
ness of the epidemic parotitis, the face is not disfigured to such a 
degree, and the lobe of the ear is never pushed so far upward. The 
symptoms are limited to a slight swelling, and to pain upon pressure 
from without, and on mastication. The lymphatic glands Ijing around 
and upon the parotid, and which, in affections of the mouth, swell up 
earlier and oftener than the parotid gland, render the diagnosis mate- 
rially difficult. The best diagnostic cardinal points will always be the 
position of the lobe of the ear and the course of the disease. Thus 
the tumefied parotid undergoes resolution sooner and more regularly 
than the cer\dcal lymphatics, which often become indurated, or degen- 
erate into suppuration. In rarer instances, it may also terminate in 
suppuration, whereby severe general phenomena, a tardy increase in 
the size of the gland, and, finally, fluctuation and pointing, will take 
place. After a profuse and exhausting discharge, the process termi- 
nates in complete atroj)hy of the suppurating gland. As secondary 
parotitis is usually confined to one side, and as the mouth is thereby 
very severely affected, nothing definite can therefore be stated regard- 
ing the character of the salivary secretion of the diseased gland. 

The treatment is iDrincipally to be dkected to the disease of the 



DISEASES OF THE DIGESTIVE APPARATUS. 115 

mouth, for which kali chloricum must again be mentioned as the 
sovereio-n remedy. The remainder of the treatment of the aifection 
of the mouth viHi be found already described in the corresponding 
chapter. 

(c.) Iletastatic parotitis occurs in the course of typhus or scarlet 
fever, of variola, of measles, and generally in the first few days, at the 
chmax of the disease, in which case death almost invariably follows, or 
with the ushering in of convalescence, and then a far more favorable 
prognosis may be given. The etiological connection of parotitis with 
these exanthema is very uncertain. Among other causes, especially 
for t}^hus fever, a mechanical occlusion of the ductus Stenonianus, as 
a result of the dryness of the mouth, must, at any rate, hold good. In 
the cadaver, the parotid and its contiguous parts are found swollen, and 
the gland itself dotted with a number of small abscesses, the contents 
of which are either yellow thick pus, or brown sero-sanguinolent ichor. 
In grave putrid fevers, a general gangrenous sloughing rapidly ensues, 
by which the entire gland and its adjacent textures degenerate into an 
ichorous, brownish-green, fetid, decomposed mass. 

The symptoms vary in accordance with the degree of the general 
affection. If the typhus fever or the acute exanthema has reached an 
intense degree, the patients will be totally unaw^are of the existence 
of the comphcation ; if, on the other hand, it comes on during conva- 
lescence, they will present the same subjective phenomena as in the 
idiopathic, epidemic form. In general, it may be stated that metastatic 
parotitis runs a slower course, and much more frequently degenerates 
into suppuration, than the secondary, and still more than the idiopathic. 
Here the transition into suppuration takes place very often. The ob- 
jective signs, size, extent, and hardness of the tumor, are of the same 
character as in the epidemic parotitis. Although, in the other forms, 
the question, whether, in reality, the glandular parenchyma, and not 
the connective tissue surrounding the entire gland, and existing be- 
tween the acini, is affected, must still remain undecided, nevertheless, 
in this metastatic parotitis, a parenchymatous disease may be as- 
sumed with certainty, by reason of the frequent and numerous ab- 
scesses found. 

The treatment^ in the gravity of the complication, plays a subordi- 
nate part. "Warm bran-bags, if the patients will tolerate them, seem 
to have a favorable influence upon the resolution of the swelling-, and 
mitigate the pain. Incisions can only be made advantageously when 
distinct fluctuation is felt. If no pus is evacuated by a deep incision, 
consequently no abscess having been opened, no amelioration whatever 
wiU ensue ; on the contrary, still greater oedema and troubles result 
from this traumatic parotitis. If the process has made its appearance 



116 DISEASES OF CHILDREN. 

during a convalescence, it will be protracted uncommonly long, and life 
will have to be sustained by a tonic and stimulating treatment, with 
wine, eggs, infus. carnis, meat, quinia, etc. 

(2.) Htpeetkopht of the Parotid Glaotd. — There is (a) a be- 
nign and (b) a malignant hypertrophy of the parotid gland. 

(a.) The benign form may originate slowly and spontaneously, but 
is oftener the result of the above-described inflammatory conditions. 
Occasionally benign, fibroid, adipose, or cystic tumors, also develop 
themselves in the gland. The integument over the benign tumors is 
always displaceable. Simple hypertrophies are always unilateral, the 
pain on pressing the gland is very slight ; the lower jaw is therefore 
always sufficiently movable, even in tolerably large swellings. It 
is differentiated from scrofulous induration of the cervical glands by 
the lobe of the ear being pushed off ; the glands are more movable, 
and generally found in large numbers. 

Treatment. — Simple hypertrophies may be made to diminish in size, 
or to disappear altogether, by an external application of iodine, once 
or twice a week, continued for some time ; benign lipoma, and other 
tumors in the parenchyma of the gland, of course, do not disappear 
under the use of iodine ; they must be removed by the knife, whenever 
they are sufficiently superficial, and it is possible to enucleate them 
vrithout too great vascular and nervous injury. 

(b.) Malignant hypertrophy of the parotid consists in the exubera- 
tion of a medullary or fibroid carcinoma in the parenchyma of the gland. 
It, however, never occurs primarily and isolated in the parotid ; in most 
instances, it appears with a simultaneous carcinomatous deposit in 
other organs, and, as carcinoma in general, is extraordinarily rare in 
children. Where the carcinoma attains to a considerable growth in- 
wardly, pressure upon the pharynx and larynx, and upon the large 
vessels and nerves of the neck, may ensue. The tumor also grows 
anteriorly, occasionally over the ascending ramus of the lower jaw, 
the contour of which then becomes indefinable. It is almost wholly 
immovable, and, according to the nature of the heteromorphous 
growth, hard (in fibrous carcinoma), or soft, even fluctuating (in me- 
dullary carcinoma). 

The integument in the first kind is immovable, having become 
identified with the hard tumor. Tuberculous infiltration scarcely ever 
occurs in the parotid. 

The treatment is as for carcinoma in general, merely life-prolong- 
ing. I am unable to say whether by extirpation of the carcinomatous 
parotid, one of the most dangerous and difficult operations in surgery, 
a child has ever been saved. 



DISEASES OF THE DIGESTIVE APPARATUS. HY 



Q.— PHARYNX AND (ESOPEAGUS. 

(1.) A^gi:n^a Toxsillakis. Cynanche (literally the "dog's col- 
lar," jfrom /ct'wv, the dog, and ayxuv, to strangle). — The tonsils are ag- 
gregated mucous follicles, which in the normal condition ought to 
project barely above the arches of the palate, between which they 
lie. On the surface facing the isthmus faucium ten to twenty excre- 
tory ducts of mucous crypts are found, which give to the tonsils a 
perforated appearance, similar to that of the shell of an almond. 
Now, these ten or twenty crypts of each tonsil are subject to inflam- 
mation and suppuration, in which, like the furuncles of the cutis, the 
contents of one or several follicles induce suppuration of their sur- 
rounding textures, and finally are discharged by an opening that forms 
in the abscess. In this process, the whole parenchyma of the tonsil 
swells up, and is much disposed to pass over into a state of chronic 
induration ; the latter condition may also originate spontaneously 
without ha\dng been preceded by suppuration of the crypts, and it 
then will be bilateral. A hollow, depressed excavation remains be- 
hind after each suppurative process, so that when the malady has 
recurred often the tonsils appear torn and ragged, but * are thereby 
greatly reduced in size. The oftener angina tonsillaris has occurred, 
all the more probable is it that all the follicles have been destroyed, 
and all further opportunities for future inflammations have thereby 
been abolished ; a rare example of a radical cure by Nature herself. 

Symptoms. — The disease begins with difficult deglutition, pain, 
heat, and dryness of the throat. The affected tonsil becomes uni- 
formly enlarged, and may be felt externally beneath the lower jaw as 
a small tumor. If both swell up simultaneously, as happens very 
often, they will touch each other; and all the symptoms become 
greatly aggravated, till finally even suffocation may ensue. Here the 
voice always becomes snuffling ; the pain radiates toward the ear ; as 
a result of the upward pressure of the posterior pillar, the passage 
leading to the pharyngeal opening of the Eustachian tube may become 
mechanically closed, and in this manner tinnitus aurium and hard- 
ness of hearing may be produced. The pain is greater on swallowing 
fluids than solids, such as bread and meat, for these, by their solidity, 
bore their way through, while fluids can only be forced through by 
the uniform pressure of the whole mouth against the swollen tonsils. 

In examining the mouth, some precautions are to be exercised ; the 
patients should be placed opposite a bright window, and at first simply 
be ordered to open the mouth, by which the entire process is often 
readily seen, especially if, at the same time, they put out the tongue 
and take a deep inspiration. If it is not possible in this manner to obtain 



118 DISEASES OF CHILDREN. 

a good view of the tonsils, tlie tongue will have to be depressed ; and to 
this, according to my experience, the children submit themseves more 
readily when it is done with the finger than spatula or spoon-handle. 
Moreover, the tongue can be depressed much deeper with the finger 
than with the spoon-handle, and the head can also be more readily fixed. 
The soft palate is now seen to be reddened and the highly-inflamed 
tonsils covered with thick tenacious mucus. They fill up the -greater 
part of the isthmus faucium. When the angina has existed for a 
couple of days, a few yellow dots will be observed on the tonsils, 
which, on puncture, emit a considerable quantity of fetid pus, and after 
a few days recovery is established, so far, at least, as the objective 
symptoms are concerned ; for, notwithstanding the loss of substance, 
such a tonsil remains enlarged for years. Acute angina tonsillaris, 
w^ith pain, difficult deglutition, and fever, in children, seldom lasts 
longer than five or six days, then the abscess bursts, or, if it does, not 
attain to suppuration, it will pass over into the chronic, painless in- 
duration. 

As regards its etiology, the disease sometimes occurs in an epi- 
demic form; generally, however, the cases are only sporadic, and 
occur in particularly predisposed individuals. Aside from this, inflam- 
mation of the tonsils is a constant attendant U23on scarlatina ; here, 
however, it does not usually pass over into the suppurative state. It 
is also sometimes met with in secondary syphilis, which, on the whole, 
manifests itself on the soft palate and tonsils more rarely in children 
than in adults. 

Therapeutics. — The treatment varies according to the age of the 
cliild. Small children under three or four years, Avho are less liable to 
this disease than those in whom the permanent teeth have appeared, 
are, it is well known, unable to gargle, and never retain water in the 
mouth, but swallow it directly. Thus, one of the principal palliative 
measures cannot be employed in these cases. The very popular eibis 
gargles mitigate the pain less and cannot remove the mucus that con- 
stantly coats the tonsils and fauces as well as cold water, which the 
patients should be induced to hold in their mouths, not gargle, till it be- 
comes disagreeable to them by its own warmth ; it is then replaced by 
fresh water. Thick cataplasms and bran-bags, in which half of the heads 
of patients are generally wrapped up, are said to accelerate suppura- 
tion, but they certainly make the head hot and discommode the child. 
I am more convinced that they produce the latter eff'ects than the 
former, and for that reason do not employ them. Rubbing the neck 
with oil soothes the pain, and does not heat the skin. In adults se- 
vere anginous troubles may be mitigated very rapidly by a few leeches ; 
in children, however, the loss of blood, and apprehension and excite- 



DISEASES OF THE DIGESTIVE APPARATUS. HQ 

meut attendant upon the application of leeches, deserve more con- 
sideration. Incisions into the intensely-swollen tonsils, with which, 
in adults, great mitigation and abortion of the pain may be effected, 
require, first of all, the consent of those to be operated upon, which is 
useless to hope for in children. But where the dyspnoea is very great, 
and suffocation imminent, they have to be made, and cannot be re- 
placed by the repeated use of tartar emetic. We succeed very rarely 
in causing the abscess to burst through retching. In that case, at any 
rate, the matter must have been very superficial, and in all probability 
would have been spontaneously evacuated in the next few hours. 

In acute angina tonsillaris we may limit ourselves, therefore, to 
gargles of cold water and inunctions of oil. If suffocation threatens, 
incisions must be made into the tonsils, and when, owing to the great 
restlessness of the child, and for want of proper assistance, these cannot 
be safely performed, then an emetic may be tried. The constipation 
that is usually present is very appropriately relieved by a mild laxa- 
tive such as decoct, tamarind, inf. rhei, or by a few teaspoonfuls of I^ . 
rhei aquosa. 

(2.) Hypekteophia Tonsillarum. — There is an hereditary hyper- 
trophy of both tonsils which develops very early in life, often in the 
second year, and is not the effect of anginas. Here both tonsils are 
equally swollen, push the soft palate forward, lock the uvula in be- 
tween them, enlarge upward toward the posterior nares, and thereby 
produce a snuffling voice. Occlusion of the mouth of the Eustachian 
tube induces tinnitus aurium and hardness of hearing. No redness, 
pain, or subjective symptoms, are present here ; the dyscophosis, the 
snuffling voice, the keeping open of the mouth both night and day, a 
perpetual snoring during sleep, are the main signs that induce us to 
examine the tonsils, which are then found decidedly enlarged, and may 
also be felt from without. 

I never observed atrophy of the respiratory muscles, and that pe- 
culiarly-shaped breast, pectus carinatum (pigeon-breast), first stated 
by Dupiiytren to be the effects of hypertrophied tonsils, or, at least, 
they did not seem to be such frequent concomitants of this condi- 
tion that an actual relative dependence might be deduced therefrom. 
There are a number of very-well-developed children who do not show 
the least trace of a pigeon-breast, or the least affection of the chest and 
thoracic viscera whatever, and yet suffer from hypertrophied tonsils ; 
and again a still greater number of children, notwithstanding perfectly 
normal tonsils, are afflicted with a very severe degree of pigeon-breast 
and imperfect development of the pectoral muscles. 

Before the commencement of puberty an arrest in the growth of 
the hypertrophied tonsils takes place, and in the adult the free space 



120 DISEASES OF CHILDREN. 

between them becomes enlarged. Children afflicted with this com- 
plaint are liable to acute anginous affections, and it is often accom- 
panied by diseases of the skin, eyes, and bones. 

Treatment. — The milder forms require no treatment at all. I have 
seen a remarkable diminution of the hj^ertrophied tonsils under the 
use of cod-liver oil for several months, given for other scrofulous com- 
plaints, but in the severest grades of the evil this remedy failed 
entirely. By cauterizations with nitrate of silver, skilfully performed, 
so as to give the children no pain or embarrassment, twice weekly and 
continued for a long time, a tolerable diminution in the size of the 
tonsils will be obtained, and in many instances the children, or rather 
their relations, will thereby be spared an operation. But where the 
evil is of a very serious degree, extirpation of the gland is absolutely 
called for ; as otherwise the children may j)erish by suffocation. The 
operation is best performed with MathieiCs tonsillotom, with which the 
gland is first transfixed and then abscised. Cliildren who are taken 
by surprise, and have no presentiment of an operation, willingly allow 
their tonsils to be embraced in the instrument, and in the next moment 
the glands are cut off, the patient hardly being aware of what has 
happened. The removal of one tonsil suffices to open the isthmus 
faucium ; sometimes the operation may be performed immediately 
afterward on the other side ; usually, however, the child resists it, and 
it is not ad\'isable to use chloroform, as the blood from the severed 
tonsil may flow down into the air-passages. 

The wound should be allowed to heal, and the other tonsil is cut off 
some other time, if the symptoms are not sufficiently mitigated by the 
first operation. The amputation of the gland by the aid of Mussex's 
forceps and knife is very laborious, and also very dangerous, on account 
of the close proximity of the internal carotid, which internally and 
behind is in relation with the tonsil, for in restless children it is lia- 
ble to be injured. 

(3.) Retrophakyngeal Abscesses. — According to BoTcai^ ab- 
scesses of the posterior wall of the pharynx may be di\dded, in respect to 
the manner of their origin, into three kinds : (a), into such as develop 
themselves idiopathically from an inflammation of the pharynx and of 
the cellular tissue surrounding it; (5), into such as form secondarily, 
the result of suppuration of inflamed cervical glands ; and (c), into such 
as are complicated with caries of the cervical vertebrae. 

In all the three forms the first symptom is always a slowly-in- 
creasing pain on swallowing, to which a certain amount of stifihess of 
the neck, in the motions of the head without any externally percepti- 
ble diseased condition of this part, soon becomes superadded. The 
voice assumes a snuffiing tone, and, on examining the mouth, the pha- 



DISEASES OF THE DIGESTIVE APPARATUS. 121 

rjngeal space is found constricted, the posterior wall of the pharynx 
not equidistant on both sides from the soft palate, and of a Livid color. 
As the disease advances, the stiffness constantly grows more marked, 
the head is bent backward, and dyspnoea appears whenever the chin is 
made to approximate the sternum. The neck in the region of the an- 
gle of the lower jaw becomes slightly thicker. Fever and restlessness 
supervene, and increase from day to day with the growth of the ab- 
scess. In the highest grade of this evil children are totally unable to 
swaUow, breathe very laboriously, \vith painfully-distorted features, 
the respirations are loud, stertorous, but not whistling^ as in croup, for 
which, at first sight, the disease might be mistaken, especially since 
here, too, the speech becomes indistinct and the voice tuneless. The 
mouth is constantly full of mucus, and finally the posterior pharyngeal 
wall, on touching, fluctuates tolerably distinctly. The abscess may 
attain to such a size as to get in front of the soft palate, which will 
appear to lie upon it. When it extends deeply downward, even the 
OS hj'oid and larynx will be pushed forward or to one side, and, when 
at last it is opened, a large quantity of matter will flow out with a 
gush, followed by an instantaneous remission of all the phenomena ; 
spontaneous bursting of the abscess during sleep is said to have 
caused death by suffocation, the pus filling up the larynx. 

In the second form, following upon suppuration of the cervical 
glands, enlarged or suppurating lymphatics will in addition be found 
on the neck ; and in the third, the most frequent kind, the preceding 
signs of disease of the cervical vertebrae for many months, such as 
pain and difficulty on rotating and bending the head backward, draw- 
ing upward of the shoulders, and hypertrophy or alterations in form of 
the affected vertebrae, may be observed. Although suppuration of the 
cervical lymphatics belongs to the common diseases of childhood, still 
retropharyngeal abscesses, resulting from this affection, are of extreme 
rarity. I have never yet met with this sequela of suppuration of the 
lymphatic glands. The prognosis in retropharjnigeal abscesses is 
always doubtful ; when they are accompanied by caries of the verte- 
brae, it is almost always of the fatal issue. 

Treatment. — Since the diagnosis cannot be established with cer- 
tainty till after the abscess has formed, but little can therefore be ex- 
pected from antiphlogistics, leeches, ice, and laxatives, still less from 
resolvents, blue and iodine ointment, tincture of iodine, and cata- 
plasms. 

Patients a few years old derive the greatest relief from pieces of 
ice in the mouth, as it exercises an astringent and local anresthetic 
influence. But when the physician has convinced himself of the ex- 
istence of an abscess, an early opening is the only means whereby the 



122 DISEASES OE CHILDKEN. 

harassing symptoms can be removed. When disease of the vertebral 
column is at the same time present, which, after all, is not very easy 
to diagnosticate, Bamberger justly advises to defer the operation until 
actual danger threatens, for the superaddition of air always accelerates 
the progress of the carious destruction of the vertebrae. If any im- 
provement in caries of the cervical vertebrae is expected to ensue, then 
constant quiet rest in bed upon the back for several months is indis- 
pensably necessary. Conjointly with this, of course, the strength is to 
be supported in every manner possible, and subsequently the attempt 
must be made to cause absorption of the hypertrophied tissues of the 
vertebras by the insertion of a seton, as well as by a long-continued 
use of iodide of iron. 

(4.) iNFLAMMATiOi!^^ OF THE (EsoPHAGUs {CEsophagitis). — Al- 
most all the affections of the mucous membrane of the mouth may 
extend down upon the mucous membrane of the oesophagus to the 
cardiac orifice of the stomach. Thus there is a catarrhal, mercurial, 
and diphtheritic inflammation of the same. Thrush also may extend 
down to the stomach. The most frequent form of disease of the 
cesophagus, however, is that produced by corrosive substances and 
foreign bodies. It scarcely ever occurs in children under one year of 
age, because these are still too simply fed, and are not apt to catch 
injurious articles and swallow them. 

The sjmiptoms of oesophagitis are as follows: Burning or lanci- 
nating pain at some part of the oesophagus, m the neck, in the back, 
between the scapulas, or in the praecordia. Deglutition is always at- 
tended by pain ; even the blandest fluid, the saliva itself, does not 
pass down without pain. Retching or actual vomiting will take place 
according to the severity of the pain ; deglutition is jDarticularly em- 
barrassed in the dorsal decubitus, for, when the head is tln-own far back- 
ward, the anterior wall of the cervical column forms a convexity which 
protrudes into the fauces ; on this account it is customary to raise the 
head of a child whenever any thing is administered to it. The thirst in 
oesophagitis is very tormenting, but, for fear of the pain, childi'en will 
refuse all drinks for days. Since the most common causes of oesopha- 
gitis are scaldings with hot water, lye, and concentrated acids, the 
princiiDal morbid lesions are therefore always found in the mouth, and 
from these a conclusion may be arrived at as to the condition of the 
mucous membrane of the oesophagus. If ulcers have formed, they will 
heal but very slowly, for the oesophagus is stretched and distended 
every time any thing is swallowed, and strictures will almost always 
be the result ; these slowly grow worse, the calibre of the tube, after 
many months, becomes contracted, and constantly grows narrower. 
Besides this oesophagitis from burns, which mainly originates through 



DISEASES OF THE DIGESTIVE APPARATUS. 123 

the ignorance or clumsiness of children, who, instead of instantly spit- 
ting out again the corrosive fluids, swallow them, there is yet an 
oesophagitis of traumatic origin. It is produced by swallowing cer- 
tain articles, such as fish-bones, fragments of meat-bone, needles, and 
by sharp bodies of all kinds which remain sticking in the gullet, and 
clumsy and rough attempts to remove them. Finally, ulcers of the 
oesophagus have also been met with as a result of the administration 
of large doses of tartar emetic, in powder. 

Treatment. — All attempts to remove foreign bodies are attended 
by the greatest uncertainty, since it is impossible to arrive at any 
exact knowledge of the place of fixture and the character of the ex- 
traneous substance. Nor are they always necessary ; for there are a 
number of articles, such as crusts of bread, hard cake of all kinds, 
even bits of wood, which, if allowed to remain for some time, become 
soft, and are subsequently carried down by some swallowed fluid. 
The longer the foreign body has remained, the more difficult it will 
be to remove it, because the inflammati^on of the oesophagus constricts 
its cahbre. The attempt to push down sharp objects into the stomach 
may terminate disastrously, for it is just as easy to push them through 
the coats of the oesophagus as into the stomach. If the foreign article 
does not completely fill up the calibre of the gullet, as is scarcely ever 
the case with sharp or angular objects, it may sometimes be removed 
by an instrument let down over it, at the end of which there are a few 
blunt hooks, or by one that may be mad.e to unfold after the manner 
of an umbrella. 

Against chemical burns, if they are of but very recent occurrence, 
antidotes — acids against alkahes, and vice versa — must be administered 
properly diluted. Subsequently emulsions are to be given, and, to 
palliate the thirst, bits of ice are allowed to be melted in the mouth, 
if the child obstinately refuses to swallow. It will scarcely be neces- 
sary to prohibit the partaking of solid nutriments, as the mere attempt 
causes intense pain. If the pain is very severe, warm-water com- 
presses should be apphed to the neck, and opium given according to 
the age of the child : to a child two years old, one drop of laudanum ; 
to one of three years, two drops, and so on, one drop more for every 
additional year. A very disagreeable and frequent termination of 
ulcerations of the oesophagus, such as result from chemical or me- 
chanical irritants, are strictures, which must be prevented by the pas- 
sage of bougies, after the manner of strictures of the urethra. Where 
they already exist, the frequent use of the bougie is the only means 
of saving the patient from starvation. 

(5.) Congenital Fistula of the Neck {Fistula Colli Congen- 
ita). — A very rare, imperfectly-described, almost problematical dis- 



124: DISEASES OF CHILDRE^T. 

ease. I have never had an opportunity to see it. According to 
Bednai\ it is indebted for its origin to the second or third gill-fissure 
remaining open. According to the same author, its external opening, 
in the environs of which the integument is firmly adherent to the 
subcutaneous cellular tissue, and forms a depression, is found in the 
lateral region of the neck, at a distance of half an inch fi'om the 
clavicle and its junction with the sternum. Its internal opening 
either terminates in the head of the oesophagus, near the epiglottis, 
or in a cul-de-sac near it. The secretion of this fistula is a thick, 
tenacious mucus, and is discharged mainly during mastication and 
deglutition ; water injected into it excites acts of deglutition. 

All attempts to cure this deformity by means of cauterization have 
hitherto proved fruitless. 

(6.) Sclerosis op the Steexo-cleido-mastoideus Muscle. — 
In the first weeks of life a peculiar, cord-like thickening of one of the 
sterno-cleido-mastoid muscles occasionally occurs, the pathology of 
which is as yet by no means clear. The induration is evidently situ- 
ated in the muscle, not over or near it, always occurs unilaterally, has 
a cylindrical, lead-pencil-like form, and is from one-half to an inch in 
length. In most instances the tumor is tolerably movable, becomes 
more marked during the pressin-e of the abdominal muscles upward 
(during the act of inspiration), and participates in aU the movements 
of the muscle. Paget states that the face cannot be turned toward 
the afi"ected side ; in the three cases that have so far occurred to me, 
no perceptible functional disturbance of the muscle was noticeable. 
The etiology, as given by the French ^vriters, who regard the indu- 
ration as having simply originated from a difficult labor, the use of 
forceps, etc., is not applicable to my cases, for the delivery in all 
three cases took place without any assistance from art, and the tumor 
was not noticeable till a few days after birth. The supposition of its 
being a tumefied l^nnphatic gland is untenable, on account of its 
cylindrical shape, and the absence of glandular indurations in other 
parts of the body. 

Treatment. — AU authors, Lahalbary^ MelcMori^ Dolbeau, Paget, 
"Wilks, etc., unanimously agree that the tumor disappears entirely 
after a few weeks, under the external use of iodine, and this I am 
fully able to confirm from my own experience. 

-D.—ST02IACE AJVD mTUSTmAL CAJS^AL. 

(1.) The most Bipoetaxt Symptoms of Gasteic axd Ixtestixal 
Affectioxs. — So many symptoms repeat themselves in the various 
diseases of the stomach and bowels, that it seems judicious to be- 



DISEASES OF THE DIGESTIVE APPARATUS. 125 

come thoroughly conversant with them before entering into a de- 
scription of the individual diseases, which may then be studied more 
comprehensibly in an anatomo-pathological manner. 

(a.) Dyspepsia (from ^vqikz^m^ difficult digestion). — By dyspep- 
sia is meant a complete abolition or merely a diminution of the appe- 
tite; in the latter case the ordinary articles of food are despised, 
and the patient has only a desire for delicacies, of which, however, 
he consumes but very little. The appetite is the most authentic 
index to judge a general disease by, and the examination that has to 
be instituted in reference thereto embraces the most important and 
difficult part of the whole examination of the patient. The physician 
should never be satisfied with answers embracing general amounts, 
but should ascertain very accurately the quality and quantity of 
the nourishment consumed, should have the dishes shown him out 
of which the child is fed, see how much they contained before the 
meal, and how much remained, etc., for then only can a correct 
impression be obtained of the actual or imaginary decrease of the 
appetite. 

JBantberger^ in his work on the Diseases of the Chylopoetic System, 
treats of the following four kinds of dyspepsia : 

(1.) Dyspepsia from pathological alterations of the digestive 
organs. 

(2.) Dyspepsia from quantitative and qualitative anomalies of the 
digestive secretion. 

(3.) Dyspepsia from altered nervous influence, to which also the 
secondary digestive disturbances occurring in the various diseases 
belong ; and, 

(4.) Dyspepsia from abnormal irritation of the nutriments. 

All these forms of dyspepsia occur in children just as in the adult. 
The first is the rarest ; the second is very frequent, and accompanies 
principally the augmented evacuations from the intestinal canal, 
diarrhoea. The third is present in all acute febrile diseases, and sup- 
plies the best cardinal point in judging of the severity and duration 
of the fever, and the fourth is the most frequent disease in the whole 
Psediatrica, from which the majority of artificially-fed children suffer 
the whole of the first year of life. That these different kinds cannot 
always be strictly distinguished from each other needs scarcely to be 
expressly stated, since, indeed, some are directly dependent upon 
and stand in the closest connection with each other. 

In every dyspepsia the act of digestion is not only retarded, but 
also accompanied by numerous local and general difficulties. The un- 
digested articles of food that have been lying in the stomach for some 
time constantly generate gases, which have a smell, allied, though 



126 DISEASES OF CHILDREX. 

only slightly, to some of the substances consumed, and which is to be 
distinguished from the odorless air that has simply found its way into 
the stomach by swallowing. The greater part of the gas first devel- 
ops itself in the alimentary canal and distends it, by which pains are 
produced on toucliing the abdomen, or moving the body, which, as a 
rule, terminate with the discharge of a large quantity of flatus. Some 
children, suffering from disturbed digestion, complain also of a feeling 
of pressure, of fulness and pain in the prascordia, and a consecutive 
frontal or parietal pain almost invariably becomes superadded, which 
does not disappear until the appetite has returned. The usual 
and rapid termination of every dyspepsia, particularly if it is only 
caused by abnormal irritation of the food, is vomiting, after which 
the appetite returns, and the consecutive sym.ptoms quickly disappear 
also. 

Therapeutics. — The treatment of dyspepsia calls for a thorough ex- 
amination into its causes, and, according to these, is sometimes radi- 
cal, sometimes sjnnptomatic, and then again merely expectant. The 
cu'cumstances are often so complicated, the causes so difficult to 
fathom, that it is one of the severest tasks to estabhsh general rational 
rules for it. The whole basis of treatment depends upon strict diet, or 
the deprivation of food, as rest in general, and of the diseased organs 
in particular, forms the first princijole of therapeutics. Let the cause 
of dyspepsia be what it will, its efi'ect is always the same — diminution 
or total abohtion of the digestive abihty — and the introduction of 
liquid, and, still worse, solid nutriments, is, therefore, under all cir- 
cumstances, injurious. Where pathological " alterations of the digest- 
ive organs exist, there, of course, no impression will be made upon the 
anorexia mth any remedies, since it is only a result of the disease 
of the mucous membrane, and will persist as long as that condition 
does not assume a curative process. Dyspepsia caused by anomahes 
of the digestive secretions may often be quickly reheved by j)roperly- 
selected remedies. It often happens, especially in artificially-fed chil- 
dren, as a result of the numerous articles of food which are not yet 
adapted to the infantile stomach, that a much more acid gastric juice 
is secreted than in those at the breast, and even when the diet has 
been regTilated for a long time, so as to correspond with the age of the 
infant, this secretion still continues to be poured out in large quan- 
tities, causing dyspepsia and vomiting. This condition was known in 
the oldest times, and oculi cancrorum was prescribed for it, which, 
with justice, has been supplanted by carbonate of lime, of magnesia, 
or of soda. TVTiich of these three remedies should be selected is 
almost wholly immaterial ; they all neutralize the profuse, super-acid 
gastric juice in the same manner, and when a child has taken one or 



DISEASES OF THE DIGESTIVE APPARATUS. 127 

several grains of eitlier of these remedies, for a few days, its appetite 
and digestion ^rill be improved, provided the presumption of the 
cause was correct. 

Some children are tolerably often attacked by icterus, and in the 
first few days suffer from complete anorexia. In many instances 
I have seen this disappear at once under the use of argent, nitr., which 
in children five years old may very appropriately be given in pill form, 
each pill containing one-sixth of a grain of the salt. After three or 
four pills the appetite will become reestablished, although the icterus 
will remain for some weeks. 

Dyspepsia which accompanies febrile diseases requires no special 
treatment ; the instinct in children is still more potent and correct than 
in adults. Children with a^really hot and dry skin and accelerated pulse 
do not touch the food that is placed before them, nor do they readily 
drink any nitrogenous fluids, such as milk or soups, but always call for 
cold water, and prefer it to sweetened and acidulous drinks. There 
is no remedy for this form of dyspepsia, and, even if there were, its use 
would undoubtedly be contraindicated during the duration of the fever. 
On the other hand, it frequently happens that by the too assiduous 
administration of remedies, such as tart, emeticus, in small doses, ipe- 
cacuanha, neutral salts, acids, etc., the digestion of children is inter- 
fered with and retarded longer than the fever would last, and the 
convalescence is thereby delayed. 

In dyspepsia caused by abnormal irritation of the nutriments, the 
child is to be kept upon a strict diet for several days — nothing but 
mucilaginous broths, or milk mixed mth chamomile-tea, should be 
given ; afterward the child may be fed in the manner prescribed on 
pages 43 to 46. Calomel, in one-eighth-grain doses, given two or three 
times daily, exercises an extremely beneficial effect upon such an irri- 
table mucous membrane; it produces a few green evacuations, the 
tympanitic, distended abdomen becomes smaller, rest and sleep follow, 
and the child begins to digest again. 

(b.) Bulimia (from ^ovhfila, ravenous hunger). Polyphagia 
(from 7rolv(i)ayia, greediness). Fames Canina. — A morbid increase 
of the appetite may, it is true, also be acquired through bad habits and 
a depraved rearing, but in children it is oftener a symptom of various 
morbid conditions, above all, of intestinal worms, next of hypertrophy 
of the mesenteric glands, and of chronic cerebral affections. The rav- 
enous hunger coming on after acute diseases, particularly typhus fever, 
does not belong here, it finds its physiological explanation in the rapid 
replacement of the adipose tissues that have been lost. So also of that 
bulimia which originates in general good health, and without any dis- 
ease of the organs, must an especial disposition be assumed ; for, although 



128 DISEASES OF CHILDREN. 

very many children are constantly urged by tlieir irrational parents 
to eat, and incessantly stimulated thereto by a change of delicacies, 
still few are able to acquire this rare condition. In these cases, the 
objects with which children seek to appease their ravenous hunger 
always belong to the class of dehcate nutriments, but depraved 
longings, depending upon morbid alterations of the organs, also occur 
in greediness similar to that in pregnant women. Such children eat 
raw and bad victuals, and roots of all kinds, and refuse at no time of 
the day, not even directly after a meal, a slice of rye bread, of which 
they will consume as much as they can obtain. When this condition 
cannot be remedied sulficiently early, it becomes chronic, without the 
children increasing thereby in size and weight faster than those who 
are more moderate. On the contrary, they generally look pale and 
ansemic, have frequent evacuations, putrid-smelling stools, and are 
retarded in growth. At the autopsy, an extraordinarily large stomach, 
with thickened walls, and those morbid alterations already mentioned, 
are usually found. 

Therapeutics. — The treatment is successful and rapid, if intestinal 
worms which may be expelled by the various anthelmintics are the 
cause of the polyphagia ; but unsuccessful if, as in atrophic children, 
the mesenteric glands are collectively hypertrophied and infiltrated, or 
when a chronic hydrocephalus is the cause of the bulimia. Here we 
have to limit our efforts to supplying at least easily-digestible, bland 
nutriments; it will scarcely ever be possible to diminish them in 
quantity. 

(c.) Y^omiting (Vomitus). — Vomiting has frequently a different 
signification in children from that in adults. A great number of in- 
fants, as often as they have been nursed, throw ujd the greater part 
of the milk mthout any retching, without any distortion of the 
features, and without any consequences ; this occurs all the more 
readily if they have been moved about or dandled up and down after 
nursing. This vomiting is very much facilitated in children by the 
almost total absence of the blind sac, the fundus ventriculi, on ac- 
count of which the contents of the stomach are not, as in the adult, 
driven toward the fundus during its peristaltic action, but forced 
directly into the cardiac orifice, and, when that opening is incom- 
pletely closed, a regurgitation of the food will immediately take 
place. When the physician has an opportunity to see undressed 
infants vomit, he will readily convince himself that no abdominal pres- 
sure whatever takes place, but that at once, while the children are 
respiring normally, and displaying all the signs of perfect health, the 
milk flows quietly out at the mouth. They do not, on the whole, throw 
up very large quantities of milk, and thrive excellently in this condi- 



DISEASES OF THE DIGESTIYE APPARATUS. 129 

tion, so that the old proverb of the nurses, " spitting children, thriving 
children," must be accepted as true. 

This vomiting occurs only in infants at the breast ; those brought 
up by the hand, it is true, also vomit very often, but here nausea, 
sleeplessness, and hot state of the body, precede the vomiting ; the act 
itself is combined with retching and contractions of the abdominal 
muscles, and its effects are digestive disturbances of all kinds and 
emaciation. The matter vomited does not consist purely of the undi- 
gested nutriments, of the cow's milk, of the broth, or the soups, but a 
large quantity of mucus is already mixed with it, and the cow's milk 
is curdled into large lumps. Those who see a child of about five years 
old affected with nausea, consider it dangerously ill, near its death ; 
the face turns deathly pale, the forehead becomes covered with a cold 
perspiration, the eye is heavy, the respiration profound, labored, and 
uTcgular ; the pulse is so small that it is barely perceptible. It lays 
down and moans lowly ; occasionally it puts its hands in the mouth, 
and bears an expression of the utmost anxiety upon its countenance. 
This condition may last several hours. Suddenly violent vomiting 
comes on, a large quantity of liquid food flows out of the mouth with 
a gush, a few retchings follow, accompanied by a loud outcry of the 
frightened child, and the whole morbid picture is instantly gone. 
Then, as a rule, a deep, long sleep succeeds, after which, if only an 
overloading of the stomach mth coarse, undigested food was the cause, 
the child will wake up perfectly well, or at the most will suffer for a 
short time from a diminished appetite, and have a furred tongue. 

When children are attacked by an acute exanthema, typhus fever, 
or pneumonia, vomiting of the last-enjoyed meal, as a rule, takes 
place in the first day of the disease ; if that does not occur spon- 
taneously, I limit myself to mechanical means to induce it ; ipecacu- 
anha and tartar emetic should never be used, because they invariably 
act upon the bowels at the same time, and diarrhoea only aggravates 
the diseases. 

If a round worm has found its way into the stomach — an accident 
which happens but very rarely in children under one year of age, but 
in larger ones, on the contrary, tolerably often — then the acid contents 
of that viscus seem to disagree with it ; it moves rapidly about and 
excites antiperistaltic actions and vomiting, by which, to the great 
horror of the inexperienced parents, it is expelled. No bad effects 
are usually observed from this ; in general, however, such children are 
always afBiicted with a great number of ascaris" lumbricoides, and it is 
well to give them some vermifuge a few days after the vomiting-. 

The vomiting in acute cerebral affections, in commotio cerebri, and 
particularly in hydrocephalus acutus, is of a very peculiar character. 
9 



130 DISEASES OF CHILDREX. 

When children affected "vvith these diseases are turned over upon the 
other side or set upright, then suddenly, without their becQming 
thereby unpleasantly affected, if they are otherwise in possession of 
their faculties, a gush of muculent, white, or yellowish-green water 
will come out of the mouth, after which, without suffering any retch- 
ings or nausea, they Avill take to drink again or continue to sleep. All 
cases should therefore be carefully examined and closely observed, 
whether nausea and retching precede the vomiting or not. When 
these symptoms do not precede, then we have to deal with very serious 
cerebral vomiting, from which the vomiting of healthy nurslings first 
spoken of, and which also occurs without retching, makes the only 
exception. 

Treatment. — The vomiting of nurslings should not be interfered 
with so long as the nutrition of the child does not suffer therefrom, 
and no large quantities of milk are thrown up. But, when this is the 
case, the nursing of the child must be conducted in a different man- 
ner ; it should not be allowed to drink until it forsakes the breast of 
its own accord, but should be taken from it after half that time, and 
laid down as quietly as possible. The crying that results therefrom 
soon ceases. By this procedure alone it is usually possible to prevent 
the too frequent and copious vomiting. If, however, this does not 
answer, a few teaspoonfuls of sweetened strong chamomile-tea should 
be given before the child is put to the breast. 

The vomiting of artificially-nourished children is always a sign of 
enfeebled digestion, and is, under all circumstances, to be corrected. 
Here the treatment with carbonate of Kme or carbonate of magnesia is 
excellently adapted, and leads, if in addition the diet is properly regu- 
lated, to the most satisfactory results. If the intestines are at the 
same time affected, if diarrhoea is present, these must be cured before 
a cessation of the vomiting can be expected. Here also, calomel, given 
in gr. one-sixth two or three times daily, stands at the head of the list 
of all known remedies. 

^'\'Tien it is supposed that the child is nauseated, and only in con- 
sequence thereof is affected with restlessness and anxiety, then, for 
the mere purpose of inducing the act of vomiting, mechanical means 
alone usually suffice. The surest one is the direct compression of 
the stomach, which I accomplish by exercising a gradually-increas- 
ing pressure with the ends of the fingers from above the navel tow- 
ard the praecordia, accompanied at the same time by a rotary 
motion of the hand, whereby usually violent, sometimes perceptible 
contractions of the stomach ensue. If this procedure does not cause 
vomiting, I introduce the right index-finger into the mouth, depress 
th^ tongue and tickle the soft palate. If no vomiting follows upon 



DISEASES OF THE DIGESTIVE APPARATUS. 131 

tliis manipulation, then it ma^j safely and surely be concluded that 
the child has no nausea, and that an emetic will hardly produce any 
favorable change in the condition. If the physician believes he has 
seen very jDositive signs of nausea in a child, which could not be 
made to vomit by these means, four to eight grains of powdered 
ipecacuanha should be strewed upon the root of the tongue, the jaws 
being kept apart with the fingers of the left hand, after which a few 
teaspoonfols of water are administered. If this quantity is insuffi- 
cient, he may rest assured that the stomach has no contents that 
oppress it, and that by stronger emetics a vast amount of harm will 
be done. 

The vomiting of cerebral afi'ections is only symptomatic, and to 
my knowledge cannot be arrested nor even mitigated ; when, in very 
rare instances, the acute hydrocephalus improves, the vomiting will 
cease spontaneously. 

Vomiting that occurs in commotio cerebri, produced by a blow or 
fall, if no injury to the cranial bones nor cerebral heemorrhage has 
resulted, lasts only one or a few days, and then gives place to a com- 
plete recovery. 

(d.) Flatulence and Colic. — If the gas, that is always physiologi- 
cally present in the stomach and bowels, increases in quantity, and 
the peristaltic movements of the intestines do not become accelerated 
to such a degree as to expel it by the anus, a distention of the stomach 
and bowels is produced, and, as a result thereof, an augmented ten- 
sion of the abdominal walls, which, if acute, has been called mete- 
orismus; when it has become chronic, flatulence, or tympanites. 
For this augmentation of gases the intestines are in greater part 
indebted to their own secretions ; for at no time is it more constant 
than immediately before and during diarrhoea. Constipation, it is 
true, also tends to flatulence ; it is, however, never so frequent nor 
so decided as that which accompanies diarrhoea. A diminution of 
the tone of the gastric and intestinal muscular coats is also always 
necessary, to produce a more intense degree of meteorism, without 
which the gases that originate would be quickly propelled toward 
the anus and be expelled ; this happens principally in typhus fever, 
sometimes also in the acute exanthema. The nutriments with which 
children under one year of age are supplied — bread, milk, broths, and 
amylacea — never cause any flatulence so long as they are tolerated ; 
but when diarrhoea comes on, then it cannot be decided whether the 
intestinal distention is a result of the nutriments or of the intestinal 
secretion. 

Mechanical obstructions, carcinoma of the stomach or alimentary 
tube, strangulated hernife, peritoneal adhesions, constricting cicatrices 



132 DISEASES OF CHILDREX. 

of ulcers, Avliicli in tlie adult cause such dangerous, almost fatal tym- 
panites, occur but very rarely in children, in nurslings never. 

Symptoms. — By flatulence we understand an enlargement of the 
abdomen, which may affect either the whole of the abdominal cavity 
or only some parts of it, according as the stomach and the whole 
of the alimentary canal, or only certain sections of the latter, become 
distended. 

It is usually assumed that, when the abdomen has a conical shape, 
the small intestines are dilated, when it is barrel-like distended, the 
large intestines are expanded, in which case, however, a complete 
cut-off would certainly have to exist between the large and small 
intestines, since air in spaces that communicate with each other must 
effect equal tension, and uniformly expand their boundaries. That 
such a complete cut-off ever takes place at the ileo-cjecal valve is not 
probable, but an inequality in the tone of the muscular coat of the 
large and small intestines is very likely to happen. 

In acute diseases, particularly in abdominal typhus, the condition 
becomes materially aggravated by the tympanitis, for the lungs and 
heart thereby become compressed, and thus dyspnoea and disturbance 
of the circulation are liable to ensue. 

Colic is a j^ain that originates in the walls of the intestines ; it is 
mostly paroxysmal and exacerbating. It is, of course, only a symp- 
tom, in fact, of the most varying diseases of the abdomen, but flatu- 
lence is its most frequent causation, of which colic is the most 
constant symptom. In addition, colic pains occur in children, with 
every diarrhoea that has originated in consequence of anomalous 
irritations of nutriments, and are never absent when material alter- 
ations of the intestinal mucous membrane, when enteritis folliculosa 
or dysentery, even in their mildest forms, have once developed them- 
selves. 

Large quantities of round worms may produce \dolent colic pains ; 
single round worms fi-equently pass off from the children, having pro- 
duced no colic jDains whatever, nor displayed any symptoms in par- 
ticular, as will be shown more fully further on, in the study of 
entozoa. There are also some children, who, every time they have 
caught a cold, especially if their feet have become wet, are suddenly 
attacked by colic, without the digestion before or during it being 
materially interfered with. Such children usually do not tolerate 
baths, nor even ablutions with cold water, but often for years have to 
be washed with warm water, and then only with the utmost pre- 
caution. 

The s\T2iptoms are usually as follows : Sudden painful contractions 
of the angles of the mouth and of the countenance in general, sudden 



DISEASES OF THE DIGESTIVE APPARATUS. I33 

loud continuous crying, restless movements of the arms, stamping 
with the feet, contractions of the lower extremities upon the bodj^, 
painfulness of the abdomen, increased on touching,. and tympanitis; 
in boys the scrotum is in a state of extreme contraction. Generally 
a discharge of gases or of fluid feeces soon takes place ; vomiting, 
also, fi^equently follows. In very nervous children, and when the 
colic is of an extreme degree, convulsions may ensue. The principal 
cardinal points in the diagnosis are the complete intermissions of the 
pain, and the preceding digestive troubles. 

After all, the physician should never depend upon the statements 
of the parents, who are very much given to exaggerate every restless- 
ness of the child into colic pains ; he should cause the child to be 
completely undressed, and uninterruptedly watch it for ten or twenty 
minutes, and carefully examine it. Many mothers look upon the 
colic-cry as a hunger-cry, and hasten to fill the mouth of the child 
with milk, or even broth, and, what is very remarkable, they often 
succeed in quieting the child with a few teaspoonfuls, but only for 
a few minutes, and then, in consequence of the irritation produced by 
the newly-introduced food, it sets up a still louder and longer cry. 

Therapeutics. — The treatment of flatulence has for its object the 
expulsion of the gas from the alimentary canal, and this is best achieved 
by clyster^. In most cases an ordinary injection with warm water, to 
which a few teaspoonfuls of oil have been added, suffices ; should no 
copious evacuation of faeces and gas follow, a clyster of cold water, 
without oil, or of a strong warm infusion of chamomile, may be tried ; 
the former tends to produce a sudden acceleration of the peristaltic 
action of the whole intestinal canal, which is often accompanied by 
manifestations of pain, and is therefore not appropriate when the coHc 
preponderates; the latter, on the contrary, is principally directed 
against the cohc pains, and acts more as an anti-spasmodic than as 
a gas evacuant. Bladders filled with ice or cold w^ater, or compresses 
applied to the abdomen, so much advocated in adults, act very un- 
favorably in small children, and aggravate the pain, without being 
followed by any relief. Temporary benefit can only be derived from 
such a method of treatment; an impression upon the causes of the 
flatulence cannot be made until the entire nutrition of the child 
has been examined, and the action of the various articles of food accu- 
rately observed. Through this examination it becomes evident, as 
already stated, that the diarrhoeic intestinal secretion generates large 
quantities of gas before it is evacuated, and consequently all articles 
of food, which cause the children slight diarrhoeic stools, produce 
directly also flatulence ; the most cominon preparations that 'belong- 
to this category are the gruels, and especially all those prepared 



134: DISEASES OF CHILDEEX. 

with cow's milk, and amylaceous broths ; children at the breast rarely 
suffer from flatulence. It follows, that children about to be brouo-ht 
up by hand, who are predisposed to colic, must soon be habituated to 
meat-soups, which at first should be given slightly sweetened, and but 
once a day ; later, twice daily, and without any sugar. I do not con- 
sider it necessary to restrict children to any particular kind of meat — 
veal and chickens are unnecessary luxuries — the main thing is that 
the soups are not too concentrated nor salty, and should be freed 
from oil-globules as much as possible. The best material to give the 
soup suitable consistence is pulverized wheat bread ; rice, groats, and 
mucilaginous soups are not tolerated long. 

During the attack, colic requires a symptomatic, and, subsequently, 
a causative treatment. The symptomatic treatment consists either 
in a cautious employment of narcotics, particularly the preparations of 
opimii, of hydrocyanic acid and nux vomica, or in ethereal, aromatic 
remedies, chamomile, peppermint, or mehsa teas, apphed per os et 
anum. Above all, it is necessary to keep the patients warm ; this is 
readily accomplished by wrapping them up in warm clothes, by ap- 
plying to the abdomen bottles filled mth warm water, or bags filled 
with warm chamomile-flowers ; warm drinks are also very beneficial. 

The causative treatment has for its object the removal of the differ- 
ent causes : 

(1.) Colic produced by anomalous contents of the stomach and 
alimentary canal. Here, if possible, the stomach should be evacuated 
by mechanical means, or, if not, by four to eight gTains of ipecac. 
When coarse, indigestible nutriments have once passed beyond the 
pylorus, they will produce diarrhoea by their own irritation, and there 
will hardly ever be any occasion to induce it by remedies ; on the 
contrary, it often happens that the diarrhoea has to be arrested by con- 
stipating remedies, because it has become too profuse. Worm-colic 
must be treated first by opium, to palliate the coHc ; then, however, by 
proper doses of anthelmintics to expel the worms, a more detailed 
descrijDtion of which will follow further on. Vermifuge remedies 
should never be given to a child suffering from diarrhoea and cohc. 

(2.) Cohc caused by impaction of stagnant alvine masses, owing 
to their generally rapid digestion and absorption, rarely occurs in chil- 
dren. But fruit-seeds, especially of grapes and cherries, accumulate 
into large lumps, and the stools, notwithstanding the fruits partaken 
of, remain hard, and, if a large quantity has been swallowed, intense 
cohc pains, and even symptoms of intestinal stenosis, will follow. As 
these lumps of fi:iut-seeds almost always remain in the small intes- 
tines, clysters therefore do not suffice to remove them ; an augmenta- 
tion of the intestinal secretion must be obtained, to soften and make 



DISEASES OF THE DIGESTIVE APPARATUS. 135 

" them liquid, for which purpose a few large doses of calomel, of four 
to five grains, will be found to answer. 

(3.) Colics depending upon textural alterations of the alimentary 
canal only require a symptomatic treatment, as has already been stated 
above ; the treatment of the textural diseases will be given more in 
detail in connection with their descriptions. 

Lead colic, arsenial colic, and all other toxical colics in general, must 
be treated as in the adult, by the respective antidotes which toxi- 
cology prescribes. 

(e.) Dlarrhcea {otappoia, from dia, and peu, I flow). — By diarrhoea 
we imderstand a qualitative and quantitative derangement of the ex- 
crements. The quality of the excrement evacuated is, aside from the 
chemical and microscopical properties, subsequently to be elucidated, 
in so far changed that it no longer possesses the semi-solid, pap-like 
consistence, but is now a watery liquid alone, or watery liquid in which 
fecal matter or remnants of food are suspended. The quantity is always 
increased in diarrhoea, but no very precise amounts can be given, be- 
cause, in the infantile age the stools cannot be properly collected, and 
the measurements give therefore only an approximative result ; the eye- 
measurement, however, suffices completely to confirm the statement 
that a larger quantity of alvine matter is evacuated in diarrhoea than 
in the normal state. That the anus has to open itself oftener than 
usual, in order to expel a larger quantity of excrement, requires no 
further comment. Owing to the irritation which the liquid alkaline 
intestinal contents exercise upon the sphincters, the defecation takes 
place oftener even than would be absolutely necessary in conformity 
with the total quantity of the faeces evacuated. 

Various kinds of stools may be distinguished, according to the 
form, color, and smell ; a'nd furthermore, according to the chemical 
and microscopical properties. 

The normal form of the infantile faeces in the first year of life is 
the pappy ; the color is yellow, like that of the yolk of egg ; the smell 
is feebly acid, never putrid, and, only in children who are fed upon a 
meat-diet, as repulsively pungent as in the adult ; in later years they 
are no longer to be distinguished from those of the adult. 

Diarrhoea may consist simply of softer, more fluid, but yellow-dyed, 
and still feculent matters — diarrhoea simplex, stercoralis sive fusa — 
or undigested articles of food pass off with such constituted stools, 
a condition that has been called diarrhoea lienterica, lienteria (from 
Mov^ smooth, and hrepov, intestines, leevitas intestinorum). These 
occur extremely frequently in artificially-brought-up children ; for 
the careless parents try from time to time whether they might not 
finally cease preparing extra dishes for the child, and allow it to 



136 DISEASES OF CHILDREX. 

eat from the general clisli. They give the children meat, vegetables, 
and fruit. Occasionally, finely-cut pieces of meat are digested ; as a 
rule, however, the children, for want of teeth, s^vallow larger pieces, 
which the gastric juice is incapable of dissolving, and these now pass 
through the whole of the intestinal canal as foreign bodies, and un- 
dergo decomposition. Vegetables and raw fruit are generally dis- 
charged in an undigested state, and often cause a very profuse, dan- 
gerous diarrhoea, sometimes none whatever. 

Again, there are diarrhoese where the bright-yellow evacuations 
are so thin that they squirt out from the anus as from a syringe, and, 
like water, soak through the diapers and bedclothes. They occur 
principally in cholera nostras and asiatica, and in children who have 
only been just weaned, diarrhoea ablactatorum ; they are either totally 
odorless, or have a putrid but never the physiological acid smell, and 
never react acid, like the normal stools of children at the breast, but 
neutral, sometimes even alkaline, from the presence of large quanti- 
ties of the alkaline carbonates. If they have been collected in a clean 
vessel, and then poured into a test-tube, they will separate into two 
strata, after the manner of typhus-fever stools; the upper one is 
bright, almost perfectly transparent, the lower flocculent, and mixed 
with small brown feculent lumps; this lower layer is often very 
small, and forms but a tenth part of the upper. The microscopic ex- 
amination, besides the undigested remnants of food, such as vegetable 
cells, amyloid bodies, milk-globules, casein-coagula, etc., reveals noth- 
ing but intensely yellow or light-brown-dyed scales, fragments of epi- 
thelium-cells, and a number of bro^vn globules of various sizes, with- 
out enveloping membranes, as may be readily demonstrated by simply 
compressing them ; entire cylindrical epithelium-cells are rarely seen. 
In alkaline stools the triple phosphates ate also found. Generally 
these stools do not contain albumen, but when they have a rose or 
reddish-brown color, usually due to an admixture of small quantities 
of blood, then albumen may easily be detected by the aid of nitric 
acid. 

The green stools of children are commonly denominated " bilious," 
but without any correct foundation, for nobody has yet demonstrated 
that they contain more component parts of bile than yeUow or brown 
stools. The coloring matter of the bile is originally brown, and the 
normal faeces on that account brown; or, if the children are only 
fed upon milk, golden j^ellow. But the normal brown coloring mat- 
ter of the bile (the biliphaein) can very easily be converted by a num- 
ber of chemical agents, even by simple contact with air, into the 
gi^een (biliverdin), and this, in the medication of children, very fre- 
quently happens through calomel. The supposition that the green 



DISEASES OF THE DIGESTIVE APPARATUS. I37 

" stools, after small doses of calomel, are due to a meclianical admix- 
ture of a substance covered Avith a black coating of sulphuret of 
mercury, is erroneous ; for (1.) These green-colored stools often last 
for several days, and are of large quantities, without it being possible 
to demonstrate the presence of mercury in them after the second 
day; and (2.) The stools may be diluted with water, and filtered, 
when the latter will be seen to run through the filter very green in 
color, proving conclusively that it is not a mechanical coloring. 

In young children green stools occur during dentition, and after 
almost every intestinal catarrh produced by undigested nutriments, 
and it seems that the augmented secretion of the intestines is sufficient 
to convert the biliphaein into biliverdin. It also very frequently hap- 
pens, that the faeces are evacuated perfectly yeUow, but turn to a 
green color when exposed to the air for a few hours. This change 
of color first begins at the periphery and on the thinner layer of the 
fecal masses ; and not till some time after do the denser, principal 
lumps become afi'ected, until the whole is seen to be dyed uniformly 
green. Children with such evacuations usually sufi"er from slight 
digestive disturbances. 

In still another kind of diarrhoea, admixtures of large quantities 
of mucus occur, large and small lumps and shreds of which being 
discharged with the almost liquid intestinal secretion, having the 
greatest resemblance to the glairy nasal mucus. They may be toler- 
ably well freed from coloring matter by agitating them with water ; 
they lose, however, thereby, in transparency, and under the micro- 
scope exhibit mucus-corpuscles, fragments of epithelium, and granu- 
lar masses. The evacuations of these are attended by pain. 

In artificially-reared, slowly-developing children, gray or bright- 
yellow colored, loamy stools are sometimes met with, which may be 
smeared hke moist clay upon the diapers and with the greatest exer- 
tion only are expelled from the anus. This decoloration is due to a 
deficiency or absence of bile, or at least of the coloring matter of the 
bile, and, so far as I am aware, has no deleterious effect upon the di- 
gestion and development in particular. True, by the aid of the ex- 
tract, or a few grains of powdered rhubarb, an increased secretion of 
bile may readily be obtained ; the danger, however, is always thereby 
incurred of inducing an intestinal catarrh, the end of which it is im- 
possible to foresee ; consequently more harm may be accomplished by 
it than good. 

The odor of the diarrhoeic faeces will always be of the greatest 
importance in judging the disease of the mucous membrane, and par- 
ticularly for the prognosis. Of a number of stools, having the same 
appearance and the same degree of fluidity, some will have scarcely 



138 DISEASES OF CHILDEEX. 

any odor, others will smell simply fecal, and still others fetid and 
putrid. These last are always symptomatic of a grave disease, of 
enteritis folliculosa, which in most instances terminates in death. The 
odor is difficult to be described, but may be best compared to sul- 
phuretted hydrogen ; it is often so offensively pungent, that the care of 
such children can only be properly carried out by great sacrifices on 
the part of the attendant, the rest of the occupants of the room in 
which the child is confined being obhged to vacate it. These stools 
are also evacuated with pain, and redden the anus and its adjacent 
parts. Most frequently they are met with as accompaniments of 
thrush, in which the anus, genitals, inner part of the thighs, and heels, 
appear intensely reddened, and, in parts, also eroded. Microscopically 
and chemically, I could detect no special distinguishing characteristics 
in these stools, and, with the exception of the odor, know no pathogno- 
monic peculiarity to mention. 

Pus probably never occurs in the stools of small children ; in those 
of larger ones it may sometimes be seen after dysentery has been 
arrested. Most tubercular ulcers of the bowels are situated in the 
small intestines, and their discharges are not so copious that whole 
streaks of pus, for these only are meant, can be found in the stools. 

(f.) Ohstiioation {Ohstructio Alvi)^ Constipation. — When other- 
wise healthy children, under one year of age, have not two evacua- 
tions, and those from one to three years at least one stool a day, the 
consistence of the fseces becomes hard, and a condition results that 
has been called obstructio alvi. Artificially-reared infants are mainly 
subject to it; still it is also sometimes seen in children at the breast, 
especially in those whose wet-nurses suffer from this evil. The chemi- 
cal investigation of the milk of such wet-nurses leads to negative re- 
sults. 

The causes of constipation are found in the following conditions : 

(1.) Deficient or too tenacious intestinal mucus. The constipation 
of most febrile affections is mainly due to this condition, or to aug- 
mented perspiratory and urinary secretions. 

(2.) The nutriments, especially the amylaceous class, soups con- 
taining meal, rice, sago, etc. In older children the various dishes con- 
sisting of beans, peas, and the like. Again, all nutriments and medi- 
cines containing astringents, red-wine, the preparations of lead, alum, 
kon, bismuth, chalk, nitrate of silver, and vegetable remedies con- 
taining tannin ; all these may produce constipation, which ynil last for 
some time. 

(3.) Too slight peristaltic movement of the alimentary tube, which 
is scarcely ever observed as a primary but mostly as a secondary con- 
dition, the effect of disease in other organs. Here belongs the obsti- 



DISEASES OF THE DIGESTIVE APPARATUS. I39 

nate constipation of acute hydrocephalus, in which, notwithstanding 
its long duration, the abdomen always remains dej^ressed. In atro- 
phied children, in ultimo stadio, besides the diminution of the intestinal 
secretions, atrophy of the muscular coat of the bowels becomes super- 
added, and then constipation ensues through a double cause, and 
finally a peripheral paralytic state of the bowels also occurs, especially 
in mechanical or perforative peritonitis. 

(4.) Mechanical obstructions, incarcerated hernise, intussuscep- 
tions, tortious, complete occlusion of the calibre of the gut by firm, 
dry stercoraceous masses, etc., occur extremely rarely in children. In 
new-born children, imperforatio ani, a description of which will follow 
fmi;her on, must be taken into consideration. 

The description of the symptoms is almost exhausted by the defi- 
nition of the malady. The abdomen is distended, but, in simple con- 
stipation, not painful to the touch. The sparsely-evacuated fseces 
lay dry in the diapers, like those of the goat or sheep. Wlien the 
evil is of long standing and intense degree, the tympanitis increases 
so much as to push the liver upward ; the spleen cannot be detected 
by percussioD, and the whole abdomen feels as tense as the head of a 
di'um, on account of which, it will naturally be painful to the touch. 
Then the children leave off eating, are very restless, attacked by 
eructations, and finally by vomiting, some fetid intestinal gas passes 
off, with slight temporary relief, but all the symptoms disappear at 
once, if one or more copious evacuations have been produced. 

"When the disease is of long duration, the tympanitis becomes 
chronic. Owing to the protracted anorexia the patients become very 
much reduced, and, as a result of the continuous compression of the 
abdominal veins, a marked collateral venous circulation forms beneath 
the abdominal integument. 

In every serious constipation it is advisable to examine the anus 
and rectum with the finger, because we may thereby often dispense 
with the internal treatment. Hernia is frequently the effect of this 
evil ; and convulsions in small children. If no mechanical insurmount- 
able hinderances, as those enumerated in sec. 4, are present, the prog- 
nosis may be regarded as favorable. 

Therapeutics. — The treatment must fathom the cause ; therefore, 
the diet is, first of all, to be tested and regulated. A slight modifica- 
tion of the nutrition often suffices to relieve the evil, as, for instance, 
meal food is to be allowed only once instead of three times a day 
to the child, and more milk given than heretofore, or the very con- 
stipating mucilaginous soups are substituted by thin beef broths 
with some wheat bread, which is made to form the staple of the 
daily nutriment. In somewhat older children the stools may be readily 



14:0 DISEASES OF CHILDREN. 

augmented by allowing them boiled and also raw fruits, grapes, ap- 
ples, j)ears, etc. ; next by a plentiful supply of cold water, and it is 
especially ad\'isable to try to remedy the constipation by a change of 
diet, before aperient remedies, of whatever kind they may be, are re- 
sorted to. If no success has attended this simjDle method of subjugat- 
ing the evil, one or two teaspoonfuls of I^. rhei aquosa should be 
given, as it is always the best and least injurious. Calomel should 
never be resorted to for the mere purpose of promoting the stools, 
when no other indication for it exists, for the very reason that 
mercury cannot be cleared of the suspicion that it tends, in many 
cases, to retard the development of the child, and promotes caries of 
the teeth. A small suppository of common soap introduced into the 
rectum will frequently relieve the constipation. Clysters of cold 
water or of soap-water have the double effect of softening the hard 
fecal contents of the rectum, and, by consensual irritation, of stimulat- 
ing the whole intestines into increased peristaltic action, and of aug- 
menting the secretions thereof. But when the fecal masses are very 
compact, it will not be possible to employ clysters, for the water will 
flow out again even during the injection, and we have no other alterna- 
tive but to remove them by mechanical means, by the aid of a hair-pin, 
scoop, or the like. Constipation accompanying febrile diseases, and 
that originating as an effect of acute hydrocephalus and of peritonitis, 
very seldom become objects of special treatment, and will be spoken 
of in the relative sections. 

(2.) Cataerh of the Gasteic Mucous Membeane {Catarrhiis 
Ventriculi). — Catarrh of the mucous membrane of the stomach, or 
gastritis catarrhalis, is met with in the autopsies of many children, who, 
during life, exhibited no signs whatever of disturbed digestion. When 
we bear in mind that a bright-red color of the gastric mucous mem- 
brane is a physiological condition in the new-born, it will not be pos- 
sible to lay very great stress upon the frequently-described injections, 
and still more of the ecchymosis of that mucous membrane, especially 
as we have no guide whether any, and, if any, what symptoms are pro- 
duced thereby. Only when a blennorrhoea of the gastric mucous 
membrane has developed itself, and the profusely-secreted mucus is 
vomited several times a day, are we justified, from a clinical point of 
view, to diagnose a gastric catarrh. The causes of this afi'ection are 
as numerous as those which have been enumerated in the previous 
sections for dyspepsia, vomiting, flatulence, etc. 

Symptoms. — The symptoms of such a gastric blennorrhoea are fixed, 
continuous stomach-ache, increased on pressure, permanent distention 
of the epigastric region, perceptibly increased temperature of the 
same, and an accumulation of gas within the stomach. Warm or 



DISEASES OF THE DIGESTIVE APPARATUS. 141 

solid nutriments and warm drinks, introduced into the stomach, aggra- 
vate the pains; cold drinks, particularly cold milk, relieve them. 
True, the food is frequently thro\yn up, but upon that alone the 
diagnosis of gastric catarrh cannot be based; an emesis of pure, 
opaque, glauy, or greenish mucus, without much retching, must 
take place before or some hoars after the meal. The nutrition 
of the child is not much interfered with at first, because, as has been 
already observed, the food is not regularly thrown up, and the intestinal 
mucous membrane is still capable of absorption. But in the course of 
time emaciation comes on. In the cadaver the gastric mucous mem- 
brane is found hypertrophied, covered with a thick layer of mucus, its 
upper surface uneven and warty, a condition that has been called 
etat tiiamelonne by the French ; but it is only necessary to observe here, 
that, before a mucous membrane can be called mammellonated, the 
contracted stomach should have been stretched out to its fullest capa- 
city, for, in the strongly-contracted stomach, every mucous membrane, 
even the healthiest, will assume a warty appearance. The rest of the 
symptoms enumerated in text-books, those regarding the pulse, the 
general condition, the stools, the urine, etc., are not sufficiently char- 
acteristic to deserve a place here. 

Therapeutics. — The chief object of the treatment is to regulate the 
diet, and nothing but cold milk should be allowed for several days. 
Against the profuse secretion of the mucus, nitrate of silver has proved 
to be a sovereign remedy. To small children under one year and 
up to two years of age, I give a solution containing nitrate of silver, 
gr. ss. to water | iij, without syrup, or any mucilaginous addition. 
To children several years old who are adepts at swallowing pills, -|- 
gr. nitrate of silver each will be found to act better than the solution. 
I recollect but a single instance, that of a boy eight years old, in 
whom I was unable to accomplish any satisfactory results with this 
method of treatment. For ten days he took four to six nitrate-of-silver 
pills without any efi'ect, whereupon I ordered him five drops of creosote 
in five ounces of mucilaginous vehicle, and, to my great surprise, the 
vomiting of mucus was suddenly arrested by it. Nitrate of silver, 
caeteris paribus, will always be preferable to the creosote, owing to 
the unpleasant odor and disagreeable taste of the latter. Compare the 
treatment of vomiting, page 130. 

(3.) Toxic Inplammatio]^- of the Stomach. — All children are 
lickerish, and junket whenever they get a chance, and thus it not un- 
frequently happens that children from one to five years of age, espe- 
cially in manufacturing cities, where a great deal of strong acids and 
caustic alkalies are used, hurriedly swallow large quantities of sul- 
phuric or nitric acid, caustic alkali, caustic lime, common lye or car- 



142 DISEASES OF CHILDREN. 

bonate of soda, and a considerable quantity may have already found 
its way into the stomach, before they become aware of their dis- 
astrous error. The discussion of the general effects of caustic poisons 
belongs to the forum of Toxicology ; we will therefore limit ourselves 
to a description of the morbid changes of the stomach and intestines. 

Sym];)toms and Ayiatomo-pathological Characters. — The state of 
the mouth is the surest index by which to judge of the lesions within 
the stomach. Its mucous membrane, from any concentrated caustic, is 
found converted into a whitish-gray mass, on the removal of wliich 
the submucous tissue is seen to be dark-red, and sometimes bleeds 
considerably. Only in case nitric acid has been swallowed will the 
mucous membrane be dyed yellow, and less softened than shrunken. 
If a large quantity and very concentrated caustic has been introduced 
into the mouth, the submucous tissue will also be implicated in the 
destruction, and, at the first sight, one may be led to believe that 
he has a diffused gangrene of the mouth before him, as in noma, for 
instance. A similar condition is found in the stomach. The milder 
degrees of cauterizations with weaker escharotics, or when such small 
quantities have been swallowed that, by becoming diluted with the 
gastric contents, they are barely capable of acting as escharotics, mil 
hardly ever offer an opportunity for an anatomo-pathological examina- 
tion, for the lethal termination takes place, if at all, at a much later 
period, but in most instances does not follow at all ; in those cases 
that prove rapidly fatal the mucous membrance is found destroyed, 
in black shreds, the muscular and serous coats lax and usually per- 
forated, and the contents of the stomach already escaped into the 
peritoneal cavity. Even the duodenum may be encroached upon by 
the caustic, but the morbid appearances of the bowels, in comparison 
with those of the stomach, are very sHght. Death, by perforation of 
the stomach, happens less frequently in lickerish childreu than in sui- 
cides, who with premeditation swallow a large quantity of corrosive 
liquid, but gastric and oesophageal ulcers will frequently ensue (vide 
QEsophagitis, page 122), which heal but very slowly and with hard 
cicatrices. 

The symptoms accompanying th.ese accidents vary according to 
the quantity and strength of the escharotic, according to the depth 
it has penetrated into the stomach, and according to the quantity of 
liquid food or fluids jjresent in the stomach at the time. Usually, im- 
mediately upon the introduction of the caustic into the mouth, retch- 
ing and a spasmodic closure of the oesophagus take place, as a result 
of which it does not enter the stomach at all, but is expelled again 
by the mouth. The case is far worse when the stomach has also be- 
come coiToded. The joatients then lie in the greatest suffering, and 



DISEASES OF THE DIGESTIVE APPARATUS. 14.3 

" stir very little, because the intense gastric pains become still more 
aggravated thereby, and a bloody saliva, sometimes mixed with black 
vomited Imnps, flows constantly from the mouth. The patients are 
completely aphonic ; every act of deglutition induces the renewal of 
violent pains, or even syncope and convulsions ; a cold perspiration 
covers the face, the eyes roll anxiously about, sink deep in the orbits, 
and are surrounded by a wide dark circle. The pulse is small, scarcely 
perceptible, and the surface of the body cyanotic. If the escharotic 
has come in contact with the alimentary canal, bloody diarrhoea will 
also supervene. If the phenomena have attained the above high de- 
gree of severity, death soon takes place, generally from perforation 
of the stomach ; and, even if the latter does not happen, it apparently 
occurs in consequence of paralysis of the pneumogastric nerve. When 
death does not ensue in the first few days, recovery usually takes 
place after months of suffering, attended by alarming emaciation. 
Abnormal agglutinations, changes in form, and formations of diver- 
ticulge or strictures, may nevertheless be left behind for life. 

Therapeutics. — The treatment in poisoning with caustic or alka- 
line carbonates is to neutralize them as quickly as possible by the aid 
of diluted vegetable acids, i. e., vinegar, lemon-juice, or the like, or 
to saponify them by administering some fatty substance, such as 
almond or olive oil, which should be administered in cupfuls. Either 
of these agents may be found in every house, and therefore there is 
no necessity whatever to previously administer mucilaginous sub- 
stances, the effects of which are by no means certain ; still less are 
emetics indicated, since spontaneous vomiting always occurs without 
them, besides which the violent contractions of the stomach, induced 
by emetics, enhance the ultimate occurrence of perforation. 

Corrosive acids likewise require to be neutralized as rapidly as 
possible, and for this purpose magnesia usta is best adapted ; but, as 
this article is not often found in dwellings, it has to be sent for ; con- 
sequently, ,a certain amount of time is lost, which may cost the child 
its life ; it is best, therefore, to administer soap-water or scraped 
chalk : in the use of these, however, a large amount of carbonic acid 
is generated, which, before being expelled by eructations, may in- 
duce a dangerous distention of the stomach. Ashes and common lye 
should only be used with the greatest precautions, and greatly di- 
luted, otherwise they may themselves produce further erosion. If the 
threatening symptoms have been palliated by the means here pre- 
scribed, opium will then be the best and most rational remedy to 
assuage the pain and arrest the peristaltic action of the stomach. As 
many drops, less one, of laudanum are to be given as there are years in 
the age of the child, and this dose should be repeated every two hours 



144 DISEASES OF CHILDREX. 

till rest and sliglit narcotism ensue. In these accidents cow's milk 
has proved to be the best nutriment, upon which even older children 
may subsist for many weeks ; at first it may be given cold, and after- 
ward to suit the taste. 

(4.) The Peeforatixg Ulcer of the Stomach {Ulcus veii- 
tricuU rotundum sive perforans). — The perforating ulcer of the 
stomach is of extremely rare occurrence in children under ten years of 
age ; on the other hand, it frequently becomes developed in chlorotic 
girls before the commencement of puberty. Consequently, we have 
not strictly to treat of a disease of childhood ; we therefore only men- 
tion it for the purpose of enabling one to exclude it in a doubtful 
diagnosis of a gastric affection in a child under ten years of age. 
But when older children, especially girls, suffer from it, then its 
symptoms, pathological anatomy, termination, and treatment, diifer in 
no respect from what is observed in the adult. We therefore refer 
the reader to the classical works of Jtokitansky^ Cruveilhier, and 
]Bambergei\ in whose work on " Diseases of the Chylopoetic System " 
an exhaustive description of this condition may be found. 

(5.) H^moeehagic Eeosions oe the Gasteic Mucous Mem- 
BEAiiTE. — In many autopsies of children, who have died from the 'most 
dissimilar diseases, a varying number of minute extravasations of 
blood are seen upon the gastric mucous membrane. They appear 
either as round spots, from the size of a millet-seed to that of a pea, 
or as long, narrow streaks, and are situated upon the most elevated 
portions of the congested mucous membrane. At these points the 
mucous membrane is either of a livid color and bloody in appearance, 
or, if the disease has been of some duration, it will present the shal- 
low depressions resulting from loss of substance. Brownish-red 
fibrinous flakes generally cover such spots, and the lesions described 
are only brought into view after they have been removed. I have 
never met with an instance where the submucous and muscular coats 
were involved in the erosion. 

These erosions are most frequent and numerous in the pyloric 
region. Whether they originated in the glands of the gastric mucous 
membrane, on account of which Cruveilhier would have this afi'ection 
denominated gastritis folliculosa^ it is impossible to decide, in the 
cadaver, as the ecchymosis does not limit itself to single mucous folli- 
cles, but is diffused over large surfaces in round or oblong patches. 

The s}Tnptoms conformable with the fact previously stated, that 
the erosions may be found in the stomachs of children who have 
. died from the most dissimilar diseases, are very unreliable and insuffi- 
cient. They are frequently met with in tuberculous and atrophic 
children. They also often occur in children who have been treated 



DISEASES OF THE DIGESTIVE APPARATUS. I45 

with antim. et potass, tart, and other emetics, as ^^ell as drastic purga- 
tives, or who, toward the termination of their last sickness, suffered 
from spontaneous vomiting. On the whole, however, it would be too 
presumptuous to say that they might not be found in children in 
whom none of these conditions had existed, and who die from such 
different diseases as lobular or lobar pneumonia, pysemia, etc., so that 
it is difficult to mention any symptoms of this post-onortem condition 
which would indicate its existence during life; consequently this 
affection has only an anatomo-pathological interest. 

APPENDIX. 

SoETEXiJ^G OF THE Stomach ( Gastromalacio). — Softening of 
the stomach is not a disease, but only a post-mortem condition ; but, 
since many authors and experienced physicians still doubt its p>ost- 
mortem origin, the explanation of the condition will be given, further 
on, more minutely than its simplicity in reality seems to require. 

Before the appearance of Jllger's article, softening of the stomach 
was regarded by all as a post-mortem condition, a self -digestion of 
the stomach occurring after death; in this sense it was that Mor- 
gagni and Hunter^ later Armstrong^ Tremranus^ and Car swell, wrote 
on it. Then Jdger came forward, in 1811, with his discovery of a 
new disease, softening of the stoinach, which he described in several 
articles published in Suf eland'' s Journal of Practical Medicine. The 
symptoms of the new disease, as K^reuser afterward very correctly 
pointed out, were identical with those of common cholera infantum. 
It first manifested itself by fever, irregular breathing, pain in the 
abdomen, intense thirst, anorexia, vomiting, and diarrhoea, to which, 
in a very short time, extreme emaciation, constant restlessness and 
sleeplessness, coldness of the face and extremities, and death, almost 
invariably succeed. 

It was not long, however, before it was found that this group of 
symptoms w^as not adapted to all gastromalacige discovered at p)Ost- 
mortem examinations, and the affection was therefore divided into 
two forms, an acute and chronic. For the acute the symptoms just 
described were retained as correct, death following on the seventh or 
eighth day ; the transition of the acute into the chronic form was said 
to take place as early as the fourth day. . This latter form, however, 
it was claimed, in addition, might be developed by symptoms which 
at first were very slight, the subjects at last apparently perishing 
from atrophy. As almost every child in the course of its life has 
had one or more attacks of vomiting and diarrhoea, it was therefore 
very convenient, as often as this post-mortem softening of the stomach 
10 



146 DISEASES OF CHILDEEN. 

was found, to constitute the chronic form. That in a large number 
of children, who died from acute summer complaint, the so-called 
cholera nostras, no trace whatever of gastromalacia could be found, 
was ignored for a long time. Later on, however, doubts, as to 
whether there was any connection between the pathological condi- 
tion and the artificial complication of symptoms, increased to such a 
degree that they finally received due attention. Among these, first 
of all, was Yirchow and his pupils ; next Migel, Bednm\ Oppolzer^ 
Baiiiberger^ W. King^ and Trousseau. These were, and in part 
are still, opposed by a number of German and French physicians, 
who, according to Bcanberger, may be classified in the following 
groups : JLoiiis, Lallemand^ Billard, Michter^ and Nagel^ regard the 
softening as a product- of inflammation. Andral^ Gruveilhier, 
JBerndt., and TFmfer, believe it originates from an altered condition 
of the secretions, as well as from irritation and congestion. Jager^ 
Camerer^ Authenrieth, 8ch6nlein^ Naumann.^ Most, Teuffel, and 
others, attribute it to an altered state of the nervous system, a neu- 
rophlogosis, or neuroparalysis. Even HoJcitansJcy — at least in the 
older editions of his Pathological Anatomy — considered this as prob- 
able, and, in addition, assumed for another list of cases degeneration 
of a dyscrasic nature. Ganstatt seeks for the cause in an altered 
state of the gastric secretion, and JEismann even attributes it to a 
peculiar miasma. 

Lastly, there are a large number of physicians who would side with 
both parties, for they grant that the softening of the stomach was 
commenced during life, but claim that it reaches the highest degree, 
and even perforation, only after death. To these Chaussier, Meckel, 
and, in part also, Andral, belong. 

JElscisser, in a monograph published in 1846, threw the most 
light into this complicated dispute. Li it he demonstrated why, aad 
under what conditions, the softening takes place in one cadaver and 
not in another. But before we enter more minutely upon the rea- 
sons for the cadaveric nature of the gastromalacia, it would be best 
to describe its anatomo-pathological condition. 

By gastromalacia we understand that morbid alteration of the 
stomach, in which its coats are softened or destroyed either by an 
ulcerative process or by the formation of pseudo-plasma, indepen- 
dently of any inflammatory action whatever. The seat of these alter- 
ations, in the great majority of cases, is the blind sac or fundus, and, 
by preference, its posterior wall. ^Yhy just these parts should be 
most frequently attacked is manifest from the dorsal decubitus in 
which the infantile cadavers are always placed. The mucous mem- 
brane is always the first of the tissues attacked ; not till this mem- 



DISEASES OF THE DIGESTIVE APPARATUS. I47 

brane is destroyed does the process invade the muscular and then the 
serous coat. These conditions may be readily and clearly demon- 
strated at the points of transition, from the softened parts of the 
stomach to those which have remained uninjured. 

Two kinds of softening have also been distinguished, a gelatini- 
form and a Mack. In the gelatinous form the affected places are 
changed to a yellowish-green, jelly-like tissue, and in the -black into 
dark brown or blackish. The dark or bright color depends entirely 
upon the larger or smaller quantity of blood in the stomach at the 
time death took place. The more vascular the gastric coats are, the 
darker will the softened places appear. Sometimes the softening 
limits itself so precisely to the mucous membrane and submucous 
tissue, that the muscular coat appears as if exposed by the anatomist ; 
but when this coat also is destroyed, then the serous coat, the only 
one intact, assumes a gauze-like appearance, and readily tears in the 
attempt at removing the stomach from the abdomen. In other in- 
stances the stomach has ruptured before the abdomen is opened, 
and its contents escaped into the peritoneal cavity. But it should 
here be borne in mind that no reaction of the peritonaeum, con- 
gestion, or purulent effusions, have ever been found in such perforated 
stomachs. 

No well-defined limits of the softened parts are ever noticed, as 
they gradually become superficial and lost in the normal mucous mem- 
brane without any inflammatory or even congestive demarcation. 
As regards the contents of the stomach, JElsdsser was the first to call 
attention to the fact that a softened stomach is never found empty — 
that is, filled only with mucus, and that the liquid food always pres- 
ent has a strong acid reaction. In the majority of softened stomachs 
the contents consist of curdled milk. Often those organs adjacent to 
the stomach become implicated in the softening without perforation 
having taken place. The spleen, the left half of the liver, the dia- 
phragm and oesophagus, may be affected with the softening ; and thus 
if the latter, from rough handling of the corpse, has burst, which 
often occurs, the liquid food will be found to have escaped into the 
left pleural cavity. Even softening of the pulmonary tissues and 
liquid food in the bronchi have been observed. This will have to be 
explained by the supposition that, while the infantile corpse was 
moved about or raised for the purpose of cleaning, some of the gas- 
tric contents flowed back into the pharynx, and then through the 
glottis down into the bronchi, where this material, causing softening, 
begins to act the same as in the stomach. Moreover, in most cases, 
morbid changes are found in the rest of the organs sufficient to ex- 
plain the cause of death. The following reasons may now be ad- 



148 DISEASES OF CHILDREN. 

vanced for the post-mortem nature of tlie gastromalacia and for its 
Qon-existence during life : 

(1.) Softening of ttie stomach always affects the most dependent 
part of that viscus, in which, according to the laws of gravity, its 
contents accumulate ; therefore, under ordinary circumstances, in the 
dorsal decubitus of a corpse, the fundus, and by preference its poste- 
rior parietes, are softened. That the softemng of the mucous mem- 
brane always occurs only at those places where the liquid food has 
been in contact with them for some time, may be easily demonstrated 
in animals killed immediately after being fed with some fermenting 
substance, and the cadavers placed in different postures, upon the back, 
upon the belly, upon the right side, or hung up. Elslisser has also 
applied this test to the infantile cadaver, having placed one, imme- 
diately after death, ujDon the right side for twenty-two hours, and he 
found the fundus intact, but the right side of the stomach, the half 
toward the pylorus, in a softened state. The mucous membrane at 
this portion of the stomach was wholly converted into a muco-gelatinous 
mass, the muscular coat partially so ; the contents of the stomach 
consisted of a liquid gray material, mixed with curdled milk, of the 
odor of whey, and having an acid reaction. These experiments 
show conclusively that gastromalacia does not exist at the moment 
of death, and is only developed when peculiar gastric contents in the 
cadaver come in contact with the walls of the stomach. They show 
further that the surfaces of the stomach, in contact with its contents, 
correspond to the dimensions of the softened portions. In a body, 
which, until the p>ost-mortem examination, has laid undisturbed, the 
softening of the stomach will never be found to extend beyond the 
space embraced by the liquid food. 

(2.) Direct experiments, particularly those instituted by Elslisser^ 
and after him repeated and confirmed by many others, have sufficed 
to prove that the healthy stomach removed from a cadaver is not 
only capable of undergoing softening in any acids, but also in any 
fermentable substances, such as milk and sugar, so long as it main- 
tains the normal temperature of the body. 

(3.) Direct experiments on dogs and rabbits have proven that 
when perfectly-healthy animals, fed on milk or substances con- 
taining vegetable acids, are killed during the process of digestion, 
and allowed to remain for twenty-four hours in a proper temperature, 
softening in the highest degree and perforation of the stomach take 
place. In rabbits an almost total disapj^earance of the stomach is 
sometimes noticed under these circumstances, nothing remaining of 
the destroyed organ but loose mucus adherent to the still remaining 
portions of food. This condition is frequently met with in the 2^ost- 



DISEASES OF THE DIGESTIVE APPARATUS. I49 

mortem examination of suicides, of the executed, and, in many in- 
stances, of sudden death. 

Softening of the stomach, then, may be artificially induced outside 
of the body, in most animals, by a very simple procedure. 

(4.) Children attacked by cholera nostras, who, according to the 
alleged identity of the symptoms of cholera nostras with those 
of gastromalacia, suffer also from the latter, recover frequently, and 
immediately thereafter may die from another disease. No trace, 
however, of a cured gastromalacia has ever yet been found in the in- 
fantile cadaver ; and yet such a destruction as occurs even in the mild- 
est grade would probably give rise to marked cicatrices or contrac- 
tions of the affected parts. Nor, as has already been stated, have 
any traces of reaction or demarcation ever been found in a softened 
stomach, such as otherwise occur in all vital processes. 

(5.) The symptoms which should characterize softening of the 
stomach during life are variously given by authors. Most of them, 
in fact, describe the symptoms of cholera nostras, others observe 
cerebral compression or cerebral irritation, and still others only 
the usual atrophy, out of which the chronic softening of the stomach 
is then construed. ^Moreover, the symptoms of cholera nostras do not 
harmonize with the pathological changes of gastromalacia. It is very 
improbable that a stomach affected with softening would be constant- 
ly disposed to such active contractions as is necessary to produce the 
act of vomiting. And if the children were affected with softening of 
the stomach during hfe, and should vomit, then pure blood ought cer- 
tainly to be thrown up, for the arteries of the softened parts are not 
obliterated, as is known to all anatomists acquainted with minute 
injections. 

(6.) The nervous system has been called upon for assistance in 
various ways by the vitalists, as those physicians are termed who re- 
gard the softening of the stomach as a process which occurred during 
life, to explain their theory. The doctrine of semi-paralysis of the 
vagus nerve seemed adapted to explain all the symptoms, particu- 
larly the absence of pain and reaction, sustained as it was by the 
frequent occurrence of softening of the stomach in cerebral and 
pulmonary affections. JElscisser^ on the contrary, very appropriately 
observes that pathological changes within the cranium, like soft- 
ening of the stomach, occur frequently in children, and their coin- 
cidence will continue to be suspected as accidental, until extensive 
statistical tables shall have shown how often cerebral affections 
occur in children independently of gastromalacia, how often gas- 
tromalacia has been found by itself, and how often both together. 
According to the statistics hitherto collected, EUcisser denies the 



150 DISEASES OF CHILDREN. 

existence of a relation between cerebral affections and softening 
of the stomacli. The experiments instituted by Camerer^ to prove 
the influence of vagus paralysis, have no merit whatever. For ex- 
ample, he found that the stomachs of healthy rabbits, in which 
the contents of the softened stomachs of infants were introduced, suf- 
fered no bad effects whatever therefrom ; but in rabbits, in which the 
pneumogastric and sjTiipathetic nerves of both sides had been divided 
before the contents of such stomachs were introduced, death ensued 
in about sixteen hours, and that in one case, six and a half hours after 
death, all the coats of the stomach were found markedly softened ; in 
another, seventeen hours after death, the greater part of the fundus, 
of the stomach was dissolved. Unfortunately, he neglected to per- 
form the counter-experiment with a healthy rabbit, viz., to divide the 
pneumogastric and sympathetic nerves without introducing the con- 
tents of softened stomachs, and then observe whether softening had 
taken place. Even perfectly-healthy rabbits exhibit softening of the 
stomach under this experiment, providing the animal be killed soon 
after the contents of a softened stomach of a child, or any other acid- 
ulous nutriment, has been administered to them, otherwise the in- 
jurious contents will be propelled onward into the alimentary canal 
by the action of the digesting stomach, and thus be divided too much 
to answer that purpose. That the stomachs of rabbits thus operated 
on underwent the process of softening, although they retained vitahty 
for sixteen hours after the acidulous gastric contents had been intro- 
duced into them, is readily explained by the paralysis of the muscular 
coat of the stomach which it produces. As a result, the contents of 
the stomach remained unmoved till death ensued. But to assume at 
the same time a paralyzed state of the nerves of the stomach, and a 
"super-acid" gastric secretion, as is also maintained by some authors, 
is physiologically incorrect, because Tiedemann, and many physiolo- 
gists after him, have demonstrated the fact that, after the division 
of the pneumogastric nerves, the gastric juice is found to be neutral, 
or, at least, less acid than in the normal condition. 

Thus, then, according to my judgment, sufficiently weighty rea- 
sons have been given — each one of which is enough — to prove 
softening of the stomach not a disease ; and it is only to be wished 
that many other time-honored and unquestioned pathological condi- 
tions could also be as accurately and positively proven to be what 
they really are. 

(6.) Cataerhal Inflammation of the Intestines {Catarrhus 
Intestinalis). — As the stools of intestinal catarrh have already been 
described in the section on " Diarrhoea," it remains only for us to speak 



DISEASES OF THE DIGESTIYE APPARATUS. 151 

of the pathological anatomy of the disease — etiology, symptoms, ter- 
mination, and treatment. 

If a child acquires an acute intestinal catarrh during the last few 
days of life, and succumbs to it, the mucous membrane of the small 
and large intestines will be found generally turgid, in some places 
either dentritically injected or traversed by a diffused, livid redness, 
the injected places generally corresjDonding to the angular curves of 
the gut. The solitary glands, especially in the large intestines, are 
seen to be distinctly swollen, and to project like small whitish promi- 
nences — of the size of pins' heads — above the reddened mucous mem- 
brane. They contain the same cells that are found in them in the 
normal state, but in much greater numbers. If the intestinal catarrh 
has existed but a short time, these lenticular folhcles and Peyer's 
glands, which, in fact, are only to be regarded as lenticular follicles 
occurring in clusters, will never, or very rarely, be found ruptured ; 
whereas in chronic intestinal catarrh they are usually seen to be rup- 
tured, and here and there dyed with black pigmentary matter. Over 
large tracts of mucous membrane the newly-formed epithelial cells 
having been cast off prematurely and rapidly (the essential phenome- 
non of intestinal catarrh), do not again assume the character of primi- 
tive cyhndrical epithelium, but retain the circular form of mucus 
corpuscles. The whole mucous membrane, as a result of the aug- 
mented afflux of blood and serous exudation, becomes swollen and 
heavier. The submucous cellular tissue, in the simple catarrh, re- 
mains intact ; in the chronic it increases in thickness, as does also the 
muscular coat. The black pigmentation of the solitary intestinal 
glands, which gives to the entire mucous membrane a grayish-black 
color, almost invariably seen in chronic intestinal catarrh of adults, 
never occurs in nursHngs, nor in larger children, except faintly, al- 
though chronic diarrhoeas are usually extraordinarily protracted in the 
infant. The mesenteric glands are sometimes reddened, but never 
infiltrated and hypertrophied^ as in enteritis folliculosa. 

Etiology. — The primary idiopathic intestinal catarrh occurs in 
nurslings much less frequently than in artificially-reared children. In 
the former it is scarcely ever caused by the nutriment, mother's milk ; 
but, if the wet-nurse is unwell, suffers from diarrhoea, or is afflicted mth 
some mental trouble, restlessness, colic-pains, perhaps a very mild 
and transitory diarrhoea will attack the nursling, more or less mark- 
edly interfering with its development. Most frequently intestinal 
catarrh in nurslings originates from cold, or eruption of the incisors, as 
a result of swallowing large quantities of secreted saliva and mucus, 
and at the time of weaning (diarrhoea ablactatorum). In childi'en 
brought up by hand, the nutriment is a prolific source of the most 



152 DISEASES OF CHILDREN. 

varying diseases, particularly of diarrhoea. It has already been ob- 
served in the section on " Nutrition," that the casein of cow's milk 
curdles in the infantile stomach into large lumps, whereas that of wo- 
man's milk forms only loose flakes, by which alone the great difference 
between the freshest and best cow's milk and the milk of a wet-nurse 
may be explained. But in large cities, where the artificial rearing of 
children is of the gTeatest frequency, it is actually impossible to pro- 
cure fresh milk several times a day, and it is needless to mention the 
manifold adulterations of the milk. There is scarcely an artificially- 
brought-up child who has not suffered at least once, for a long time, 
from intestinal catarrh, and was thereby retarded in its development 
for several months. 

In children over one year of age, the process of dentition is the 
most frequent cause. Even the physiological process, as is known, is 
accompanied by a moderate diarrhoea, which, however, may be aggra- 
vated and become the most profuse, cholera-like diarrhoea, and prove 
fatal in the course of twenty-four hours, or bring on an irremediable 
marasmus. 

On the other hand, diarrhoeas, in consequence of abnormal irritation 
of the food, are less frequent in children who have passed the first year 
of hfe, for the stomach is then more capable of digesting heavier arti- 
cles of diet. In summer, before the various kinds of fruit have attained 
a proper degree of ripeness, intestinal catarrh occurs among children 
of this age, epidemically, and is usually liable to assume more of the 
character of dysentery, for, in addition to the numerous evacuations, the 
children also suffer from colic-pains, obstinate tenesmus, and some- 
times also from bloody stools. 

Symptoms. — In small children affected with diarrhoea, various 
changes may be observed even before the appearance of the principal 
symptoms of this complaint. They become restless, cry almost un- 
ceasingly, draw up the thighs, refuse the breast or sucldng-bottle, in 
short, have the various symptoms of flatulence and colic. With the 
first watery or liquid stool, if it is at all copious, almost all the symp- 
toms of colic disappear permanently, if the exciting cause of the diar- 
rhoea was only a temporary one, for example, a small quantity of 
sourish milk. This rapid subsidence, however, is seldom the case, it 
occurring almost only in children at the breast. Usually a single ad- 
ministration of sourish milk suffices to induce a severe intestinal 
catarrh that mil last for weeks. The greater the extent of the sur- 
faces of the intestines affected with catarrh, the more profuse will the 
diarrhoea be, the longer it will last, and the more severely will the nu- 
trition suffer from it. Catarrh of the small intestines causes scarcely 
any colic and but little diarrhoea, for the secretions that are then 



DISEASES OF THE DIGESTIVE APPARATUS. 153 

pom-ed out may in greater part be absorbed by the large intestines. 
Catarrh of the large intestines, on the contrary, and particularly of the 
rectum, is frequently corabined with violent pains, with tenesmus, and 
with constant profuse diarrhoea. The color of the faeces in diarrhoea is 
normal at first, but with every evacuation it loses in tint, so that final- 
ly a very bright yellow, even gray, rice-water-like fluid, without any 
smell, is discharged. The return of darker color and of odor to the 
fences may be looked upon as the most favorable sign of the speedy 
cessation of the diarrhoea. The abdomen is usually painful about the 
navel ; it is somewhat distended ; borborygmus is present ; the per- 
cussion-sound, when much fluid happens to be in the intestines, is in 
one place dull, and in another tymi^anitic. The secretion of urine is 
very much diminished ; it is very rich, comparatively, in pigmentary 
matter, and, if allowed to stand for several hours at a low temperature 
(imder 54° F. at the least), will. deposit a sediment of double urate of 
soda, the so-called brick-dust precipitate. The thirst is very great ; 
the -peculiar circumstance is sometimes observed here, that the child 
refuses to take the breast during a severe attack of diarrhoea, but 
readily drinks sweetened water, or prefers pure cold water ; as soon, 
however, as the diarrhoea is checked, it will not touch any cold water, 
and returns to the breast with its former avidity. Artificially-fed chil- 
dren will take a few teaspoonfuls of broth to allay thirst, by which 
they are quieted for a short time, but very soon become all the more 
excited by the irritation caused by the newly-administered food ; from 
this excitement they do not recover for hours. When a child is so 
unfortunate as to be attended by persons who suppose that its rest- 
lessness can be allayed by feeding it, and will therefore rise several 
times in the night to prepare pap or porridge for it, though it may 
consume but a very few teaspoonfuls, we will never succeed in saving 
it from death, unless they can be convinced of their false views and 
pernicious practice. I, at least, have never yet been able to carry a 
child through, that was nursed by such attendants. 

At the invasion of a simple intestinal catarrh, the children have no 
febrile symptoms, such as dryness or increased temperature of the 
skin; on the contrary, when the diarrhoea is profuse and colorless, 
they soon become cold, the tip of the nose white and cold, the breath 
loses its natural warmth, the lips turn pale and bluish, as do the tips 
of the fingers, and the adipose tissue that fills up the orbits disap- 
pears extremely quickly, the eyeballs sink back into the orbits, and the 
expression of the countenance peculiar to these patients results. 
But after the diarrhoea has been arrested, fever usually comes on in 
consequence of the augmented metamorphosis of the tissues, in most 
cases lasting very long, retarding the recovery, and often leading to en- 



154 DISEASES OF CHILDREN. 

teritis folliculosa and atrophy. When this fever of reaction is of short 
duration, a rapid recovery will ensue after its disappearance. The 
stools for some time will retain their abnormal quality, for they either 
become very hard or remain slimy, and then assume an offensive smell, 
the appetite returns again, and the children remain quiet after their 
meals ; this is the surest sign that the digestion again goes on with- 
out difficulty. 

The most frequent complication of this disease is catarrh of the 
stomach ; the vomiting, however, as a rule, ceases before the diarrhoea. 
Bronchitis complicates intestinal catarrh equally often. The prog- 
nosis assumes a most unfavorable aspect when the disease passes into 
enteritis folliculosa, which happens so frequently in artificially-reared 
children. 

Treatment. — In children at the breast, a mere dietetic treatment of 
the wet-nurse is usually sufficient. If she suffers from dyspepsia, with- 
out fever and intestinal catarrh, as is very frequently the case from 
emotional excitements, then her diet should be restricted for a few 
days ; she should only be allowed milk, soups, some coffee, meat-broths, 
and boiled fruits ; as a drink, almond-milk, wine-and- water, or pure 
water. The secretion of milk from such a diet, so long as there is no 
continued fever present, is never arrested ; it is at the most somewhat 
diminished, but that is very beneficial to the nursling that suffers from 
diarrhoea. 

If a wet-nurse, through some error of diet, has contracted vomiting 
and diarrhoea, a stricter regimen mil have to be instituted ; she should 
then get nothing but mucilaginous soups, wheat bread, and demulcent 
drinks, rice-water, gum- water, salep-water, or almond-milk ; and if, after 
two or three days of such a course of treatment, the diarrhoea is not 
arrested, then ten or twelve drops of laudanum are to be given to her 
immediately after nursing the child, and she should wait at least four 
hours before she puts the child to her breast. But if the diarrhoea 
nevertheless tends to run into a chronic form, and no benefit has ac- 
crued from the use of laudanum, then, while enforcing a strict diet, I 
desist from the further use of opium and give astringents, alum, tan- 
nin, Colombo, argent, nitr., etc. Medicine can seldom, if ever, accom- 
plish much in children at the breast, because most of them unwillingly 
take any thing from a spoon, and spit the fluid out again that has been 
poured into the mouth. For these reasons, the pencilling of the mouth 
with laudanum is the most convenient and practical procedure. For 
this purpose, I use a camel's-hair brush, dip it into tr. opii. c, shake 
off the first drop by snapping it with the finger and then introducing 
it into the mouth of the child, press the chin a little upward, and pull 
the brush out from between the compressed hps. In this manner 



DISEASES OF THE DIGESTIVE APPARATUS. 155 

about half a drop is left in the mouth, and, if two or three drops 
of water are dripped upon the tongue, the child will swallow all the 
fluid contents of its mouth without any delay. Usually a sleep of 
several hours' duration and an arrest of the diarrhoea follow upon this 
procedure. I have never observed from this application the bad effects, 
cerebral irritation, and cerebral congestion, which are said to ensue 
from opium, possibly from larger doses or from a long-continued use. 

Great benefit is derived, in children at the breast suffering from this 
disease, from small clysters of demulcent decoctions, barley infusion, for 
example, with one or two drops of laudanum. For the introduction 
of medi(5ines into the rectum, which in order to become absorbed ought 
to remain there for several hours, the common children's syringes are 
much too large, and I have therefore for some time been in the habit 
of using small uterine or urethral tin syringes, which I apply myself 
after having them well oiled and warmed. Quantities of two or three 
drachms are almost always retained, and the action of the opium begins 
in from thirty to sixty minutes. 

Children brought up by hand suffer from a totally different kind of 
intestinal catarrh than those at the breast, for the exciting cause of the 
disease, the unsuitable nutriment, is not here a temporary one, but is 
continued for a long time and during the sickness. In general, the 
rule holds good that 7io child with iJitestinal catarrh tolerates cow's 
tnilk, whether pure or mixed with tea or boiled into a broth with meal 
or bread, and that the diarrhoea will only exceptionally be arrested if 
a milk-diet is persevered in. The first condition, therefore, is a total 
abstinence from cow's milk. As soon as liquid stools appear, the pa- 
tients should only be allowed demulcent drinks, of which the best and 
most constipating is a decoction of salep, prepared fresh twice a day, 
by boihng as much powdered salep as can be taken up on a silver half- 
dime in ten ounces of water. In place of milk, the children may be 
allowed for their meals a thin mucilaginous beef-broth, with rice, 
barley, or groats, slightly sweetened with sugar ; it should, how- 
ever, be deprived of fat, and without salt. This diet is to be continued 
for twenty-four hours after the stools have acquired their normal con- 
sistence ; if the appetite has improved, a few teaspoonfuls of triturated 
wheat-bread may be boiled in the beef-broth. For further particulars, 
we refer the reader to the chapter on " Artificial Nutrition," p. 43. 
After the stools have been normal for at least two days, a trial may 
be made with one milk-pap each day, then with two, and finally three 
a day, and the salep-water should be continued till it may appear 
proper to substitute it by the ordinary spring-water. 

The pencilling of the mouth with laudanum and the use of opiate 



156 DISEASES OF CHILDREN. 

clysters stand at the liead of all therapeutic measures. But occasion- 
ally, in the profuse diarrhoea of summer, opium proves inefficacious ; 
then small doses of calomel, gr. -^ three or four times daily, or a solu- 
tion of nitrate of silver (gr. ss to water 5 iij), with the addition of one 
d-rop of laudanmn, without any syrup, proves more effectual. Vege- 
table remedies containing tannic acid, such as Colombo, rhatany, pure 
tannic acid itself, and astringents in general, are with difficulty ad- 
ministered to small children, unless mixed with large quantities of 
syrup, and on that account are but seldom resorted to ; in older chil- 
dren, however, they may be oftener employed. In some instances 
I have seen the diarrhoea checked by a solution of alum (gr. vi to 
mucilage | iij), though it was not possible to arrest it by any of the 
remedies just mentioned. The principal treatment will always be a 
proper prophylaxis. No cow's milk should ever be given to children, 
unless it is first rendered alkaline by adding a teaspoonful of a soda 
solution ( 3 j to water 3 vj) to every meal, as described in a previous 
chapter, and it will then become speedily evident that intestinal 
catarrhs may often be avoided, or, where they already exist, rendered 
less severe and protracted. Had I the choice, when compelled to 
treat an intestinal catarrh by the diet or by medicine only, I would 
prefer to try the dietetic treatment alone ; for I have often satisfac- 
torily convinced myself of the utter inefficacy of all therapeutic reme- 
dies in the treatment of this disease when the child is sustained on 
a milk diet. 

(7.) EXTEEITIS FOLLICULOSA AXD TaBES MeSEXTEEICA. It is of 

great practical importance to carefully diagnose between simple intes- 
tinal catarrh and enteritis folliculosa, although the anatomo-patholog- 
ical differences are not very striking, and the transitions of that dis- 
ease into the one under consideration are of very frequent occurrence. 
Pathological Anatomy. — The submucous tissue is found mark- 
edly infiltrated, so that the bowel has perceptibly increased in 
weight, and the signs of an acute intestinal catarrh are present 
upon the entire mucous membrane of the large, and upon an extensive 
tract of the small intestines, i. e., instead of the normal cylindrical 
epithelium, none but mucous corpuscles are seen. The solitary glands 
and Peyer's patches are in some parts intensely swollen, and at the 
first glance are seen to project like white nodules above the level of 
the mucous membrane ; in other parts, however, they are already rup- 
tured, and then represent empty, minute, crater-like excavations. 
These excavations occur upon the summits of the elevations origi- 
nally produced by the swelling of the foUicles. The mesentery is in- 
jected and turgid, the chylopoetic vessels are plethoric, and of a pink 
color ; the mesenteric glands in those regions corresponding to the in- 



DISEASES OF THE DIGESTIVE APPARATUS. 157 

testinal catarrh are increased in size from two to four fold ; in recent 
cases, when cut into, the incised surface presents a rose-color, 
but, when of longer duration, a yellowish-white color. The micro- 
scopic elements are the same as in the normal mesenteric glands, but 
when the color is yellowish and the gland has increased in hardness, 
the connective tissue will be found to predominate. Here, too, as in 
simple intestinal catarrh, notwithstanding the long existence of the 
diarrhoea, remarkably little pigmentation of the mucous membrane 
is found. The essential anatomo-pathological difference between in- 
testinal catarrh and enteritis folhculosa consists in the circumstance 
that in the latter the mesenteric glands participate in the disease. It 
is much to be regretted that neither by injections nor in any other 
manner can it be experimentally proven that the absorption of the 
chyle is hindered by these hypertrophied mesenteric glands, and. 
thereby the nutrition and progressive development of the child inter- 
fered with. But, when in an atrophied child, whose condition was ori- 
ginally induced by enteritis folliculosa, no changes but those indurated 
and hypertroj)hied mesenteric glands are found, the supposition be- 
comes very probable, that the passage of the chyle has been mechan- 
ically interrupted, and thus the children, although they have con- 
sumed an enormous quantity of food, and have had no diarrhoea for 
weeks preceding death, have nevertheless languished to a certain ex- 
tent for want of a sufficient supply of chyle. The term tabes mesente- 
rica of the older physicians is therefore by no means so incorrectly 
founded and obsolete as some of the later writers are inclined to rep- 
resent it. The older erred only in this, that they thought they could 
feel the enlarged glands. In this glandular hypertrophy the intes- 
tines always become tympanitic and distended, and then it is alto- 
gether impossible to feel these small tumors, which scarcely ever 
attain to the size of a hazel-nut, between or beneath the tense bowels. 
At any rate, they must be forcibly compressed against the vertebral 
column, if it is desired to feel them. 

In instances of developed tuberculosis of the mesenteric glands^ as 
it sometimes occurs in children several years old, the firm, hard, soli- 
tary tubercles may indeed be felt through the abdominal walls. But 
these are larger glands agglomerated into patches or masses, and 
traversed by deposits of cheesy tubercle. Such slight enlargement as 
is observed in enteritis folliculosa can never be detected during life 
by the sense of touch. 

Symptoms. — Enteritis folliculosa always begins -^vith intestinal 
catarrh, and consequently we may refer the student to the symp- 
toms of that disease given in the preceding section. But, instead 
of the stools becoming semisolid in a few days, and the nutrition 



158 DISEASES OF CHILDREN. 

regulated as in simple intestinal catarrh, they remain perfectly liquid 
and assume a putrid, foul odor, erode the anus and its adjacent parts, 
the inner surfaces of the thighs, and even the heels, which are 
brought in contact with the anus by contractions of the thighs and 
legs. An intense continuous fever becomes superadded, and the 
patients have a constant and severe thirst. The tongue is red and 
smooth, or coated with a white fur, and in the latter stages of the dis- 
ease almost always affected with thrush. Vomiting is frequent, but 
not present in all cases. Rapid emaciation is characteristic of the 
disease. In previously perfectly-healthy, well-nourished children, 
small wrinkles are soon observable on the inner surfaces of the thighs ; 
and the adipose tissue, that was previously firm and solid, is now 
felt to be soft and flabby. Under the continuation of this putrid diar- 
rhoeal discharge emaciation progresses so rapidly that, at the end 
of a few days, the bones of the hands and feet plainly show their 
outlines, and the integument on the thighs forms loose, flabby 
folds. On both sides, a collection of inguinal glands may now be 
detected, which also swell up to twice or thrice their normal size. 
The eyes are sunken, a deep fold forms from the inner angles to 
the zygomatic arches, the cheeks become pale and flabby, the con- 
tours of the masseters distinguishable, the chin pointed, the neck 
wrinkled, the sterno-cleido-mastoidei muscles and larynx promi- 
nent, the ribs can be counted without being touched, and the verte- 
bral column and bones of the pelvis are covered by an atrophic skin 
only. 

A very peculiar phenomenon may be observed on the occiput. 
The superior border of the occipital bone shoves itself beneath the 
parietal bones, thus forming a step, the upper plane of which is 
formed by the parietal bones, and the lower by the occipital bone. 
Exceptionally the occipital glides over the parietal bones. A sim- 
ilar but less striking displacement takes place at the frontal bones, 
the superior borders of which slide beneath the parietal. The dimi- 
nution of the cavity of the skull is caused by a decrease in the size 
of the brain, for this organ participates in the general atrophy, and, 
since it consists in greater part of fat, it must, therefore, also suffer 
a decided loss of this material. So far as I am aware, there is no 
quantitative chemical analysis of the brains of atrophic children to 
be found, it is only known that the brains of young children in 
general are poorer in fat than those of the adult ; such an investiga- 
tion is really a desirable one, and for which the Pasdiatria should 
call upon pathological chemistry. If the bones of the cranium have 
once overridden each other, and cerebral atrophy has become super- 
added, an improvement is only to be looked for in the rarest in- 



DISEASES OF THE DIGESTIVE APPARATUS. I59 

stances ; the patients almost always waste away more and more, and 
invariably perish, although they may have had no diarrhoea for weeks, 
the stools, however, retain a putrid odor, and the appetite remains to 
the last. From this atrophy of the brain (to be hereafter considered 
under the heading of Hydrocephaloid Disease) a long train of cere- 
bral*symptoms results. We find in the abdominal integument one 
of the best indices as to the degree to which the atrophy has reached. 
If, pinched and raised into a fold, it remains for some time after the 
fingers are removed, the prognosis is always, and under all circum- 
stances, to be regarded as most unfavorable ; the prospect of recovery 
always improves in proportion to the rapidity with which a fold of 
the integument thus produced disappears. 

In atrophic children with tympanitic abdomen — a condition which, 
in fact, is usually present in atrophy, as a result of enteritis folliculosa 
— small solitary tubercles of the size of pins' heads are seen upon the 
abdominal integument, united to each other by very fine cords, and 
only recognizable by the feel. These cords are not plugged-up veins, 
because veins, when the integument is so atrophied, and in such a 
superficial position, would appear bluish or black. They can only be 
obliterated veins, or, what is still more probable, lymphatic vessels — 
a supposition which may serve to explain the character of the small 
nodules. 

Treatment. — Every tiling that has been mentioned in connection 
with catarrhus intestinalis is applicable to the treatment of this dis- 
ease, as an effect of which, the infiltration of the mesenteric glands 
may be regarded. As a rule, all methods of treatment are ineffica- 
cious. There is one remedy, however, from which I have seen some 
very striking, favorable eff'ects, namely, mother's milk. Atrophied 
children, after four or even six months' disease, already at the brink 
of the grave, suffering from putrid diarrhoea, a thrush-covered tongue, 
and in incessant restlessness from pain, or tearing their faces with 
their long, lean fingers, when put to the breast of a mother, are changed 
as if by magic. At first they suck only for a few seconds, and then 
relapse again into their habitual restlessness, but, after a few days, 
nurse like healthy children, and sleep for several hours at a time ; the 
evacuations become yellow, their odor normally sour ; and they regain 
flesh and strength so rapidly that they can scarcely be recognized 
after a few weeks. Where the circumstances are such as to preclude 
the possibility of procuring a wet-nurse, the prognosis, as already 
said, is fere lethalis. In such cases I have several times succeeded in 
reducing the temperature of the skin by the use of cinchona, gr. j, 
twice daily. The atrophy also diminished, and, under an extremely 
cautious, laborious feeding, the children finally began to thrive. As 



160 DISEASES OF CHILDREN. 

an after-treatment, I^. mart, pomat., ten drops three times daily, is to 
be given for a long time. This treatment, however, generally fails, 
the temperature of the skin is diminished for only a short time, the 
patients sink httle by little, till finally, often after many weeks of 
sufibring-, they are relieved by death. 

(8.) Dysentery — the Flux. — In great epidemics of dysentery 
— such as are especially malignant in swampy regions and in the 
tropics — children under one year of age are almost totally exempt. 
A few instances are recorded, however, of women who, while suffer- 
ing from flux, gave birth to children that immediately after birth per- 
ished of dysentery. Older children, particularly after the second 
dentition, are as liable to it as adults. 

Sporadic dysentery, on the other hand, frequently occurs in in- 
fants, but, on account of its mild, almost harmless course, is not 
usually particularly watched. 

Symptoms. — The symptoms of sporadic and epidemic dysentery 
may very properly be treated of together, it being only necessary to 
observe here that the sporadic form never exhibits the intense and 
dangerous character of the epidemic disease. 

The best index of the condition of the intestinal mucous mem- 
brane is always obtained from a careful inspection and dissolution of 
the, stools. Every stool which contains a glairy mucus, formed into 
lumps, indicates a morbid alteration of the mucous membrane of the 
large intestines, or, at least, of their follicular apparatus. "With this 
glairy mucus, resembling granules of boiled starch, a few streaks of 
blood soon become associated, or the whole stool becomes uniformly 
bloody, according as the bleeding occurs near to or far from the anus. 
As this mucus increases, the proper fecal masses constantly grow less 
and less, and finallylumps of mucus, with only an admixture of fa3ces, 
are evacuated. There is, generally, no great difficulty in recognizing 
the blood that has become mixed with the alvine discharges ; if streaks 
and small lumps of blood are present, it wtII be apparent at a glance, 
and, even when the blood has been for a long time in contact with the 
mucus, a part of the blood and mucus will become thoroughly mixed 
with each other, and then they will give to the whole evacuation a 
pink or an actually red color. In fact, this discoloration alone suffices 
« to convince us of the presence of blood, because no other substance 
giving this color occurs in the f^ces. For beginners, and in the in- 
terest of clinical instruction, I will add that, if doubt of its bloody 
origin occur, it may be easily decided by the microscope. 

If ulcers form, which scarcely ever happens in sporadic flux, 
the evacuations assume a dirty-gray or grayish-red color, and a 
putrid odor, on account of sloughed mucous membrane, and large 



DISEASES OF THE DIGESTIVE APPARATUS. 1^1 

quantities of pus discharged from the ulcers becoming* mixed with 
them. The exfoliation of large patches of mucous membrane, said 
to have been frequently observed in tropical dysenteries, I have 
never observed in this country. Occasionally firmer lumps of loamy 
fieces, wrapped up in purulent or bloody mucus, pass off, although 
the rest of the symptoms do not by any means indicate that the dis- 
ease is about to be checked. These clayey lumps are, most probably, 
derived from some part of the small intestines not affected with dys- 
entery. This condition does not by any means improve the prognosis. 
For immediately after the discharge of these fa?ces, which deceptively 
indicate an amelioration of the disease, the previous state of the alvine 
evacuations reappears. 

A red and a white flux, according as to whether blood is or is not 
mixed with the stools, has been spoken of — a classification which 
naturally dispenses with all scientific basis, for it is very possible, 
indeed, for a child to have the white flux on the first day, the red 
on the second, and the white on the third or fourth again. When 
improvement actually takes place, the discharges will first assume a 
fecal odor, subsequently the normal consistency, and the muco-pu- 
rulent character gi-adually disappears. Round worms, when present, 
are invariably expelled with the dysenteric faeces. At the invasion 
of the disease the stools have a fecal odor, and this odor returns when 
the child progresses toward recovery ; at the climax of the complaint 
the normal odor has wholly disappeared, or it is sourish and un- 
healthy. In the epidemic flux, when pus and pieces of sloughed mu- 
cous membrane are ejected, the stools become intensely pungent and 
putrid, resembling sulphuretted hydrogen. Microscopical examination 
reveals mucous-corpuscles, epithelium-cells, blood-corpuscles, large ag- 
gregations of oil-globules, some particles of food, villi, and triple 
phosphates — all embedded in a molecular, finely-granular mass, whose 
chemical reaction is usually alkaline. Albujnen may be demonstrated 
to be present by diluting and agitating the stools with distilled water, 
and then filtering the liquid, and subjecting it to the appropriate 
tests. The stools vary in number exceedingly. In the milder forms, 
four to eight ; in the severer, twenty to thirty passages take place in 
the twenty-four hours, the number depending less upon the quantity 
to be evacuated, for that is often very slight, than upon the degree 
of tenesmus. 

Abdominal pains and tenesmus are never absent / the pain is 
mostly paroxysmal, but, at the climax of epidemic dysentery, children 
moan unceasing^. Touching any part of the abdomen, near the 
navel, or over the course of the colon, produces pain. The tenesmus is 
very tormenting ; the lower folds of the rectum are frequently seen to 
11 



162 DISEASES OF CHILDREN. 

protrude, presenting a livid-red color, and, notwithstanding the violent 
efforts at expulsion, scarcely a teaspoonful of mucus can be discharged. 
Prolapsus of the rectum is a frequent result of this straining. The use 
of clysters, which in dysentery has the most beneficial effect, is by 
this tenesmus rendered very difficult and often impossible. Nervous 
children are often attacked by convulsions in consequence of the aggra- 
vated pains caused by the introduction of the injection-pipe. Tenes- 
mus usually comes on with the first mucous evacuation, and remains 
throughout the disease. If the disease continues to grow worse, pa- 
ralysis of the rectum may ensue, relieving the tenesmus, but rendering 
the prognosis extremely unfavorable. 

In epidemic flux, vomiting sometimes occurs, and, if persistent, is 
a sign of commencing peritonitis. In sporadic dysentery it is only 
very exceptionally observed. 

N'o fever is usually present at first ; it appears in the course of 
the morbid alterations of the intestines. The pulse supplies no index 
whatever to the severity and extent of the lesions. The temperature 
of the skin is seldom increased ; it is usually normal, in grave cases 
even diminished. Delirium and convulsions come on tolerably often 
in nervous children, even in sporadic dysentery. 

The secondary morbid conditions of sporadic flux that should be 
mentioned are lobular pneumonia and tabes mesenterica, with infil- 
tration of the mesenteric glands. In connection with epidemic dys- 
entery, anaemia, pygemia, marasmus, intestinal perforations, peritoni- 
tis, strictures of the intestines, icterus, and hepatic abscesses, deserve 
consideration. In the sporadic form recovery may take place in from 
four to six days, in the epidemic in ten to fourteen. The emaciation 
attendant upon this disease is very great ; many children succumb 
to the sequelae who have escaped the disease. Death may take place 
either during the first few days of the disease or in the chronic stage. 

Epidemic dysentery is known to become complicated with all pos- 
sible acute and chronic affections. The sporadic principally attacks 
children in the first dentition, and older ones in the hot summer 
months, at the season of unripe fruits. 

Pathological Anatomy. — The dysenteric exudation is only found 
in the large intestines and rectum, more particularly upon the summit 
of the folds, at the flexures of the bowel, and is seen as a dirty-white, 
yeUowish-gray, grayish-red, or dark-colored layer, which often attains 
to the thickness of a line, and may be easily stripped off. The mucous 
membrane beneath it is reddened, softened, and swollen ; the internal 
surfaces of the bowel present an uneven appearance. Within the in- 
testines, the dysenteric mucus and the feculent masses are found. 
After several days this mucous membrane is cast off in fragments, and 



DISEASES OF THE DIGESTIVE APPARATUS. 163 

superficial or deep ulcers, with prolonged points and indentations, 
now make their appearance. The solitary follicles are always swollen, 
if not ulcerated. In the rest of the organs the signs of aneemia are 
found, but the peritonseum, especially the parts corresponding to the 
morbid lesions in the mucous membrane, is injected. In sporadic 
flux, extensive or deep ulcers are very rare. 

Treatment. — Uniform warmth in a well-ventilated room and spare 
diet are indispensable measures in the treatment.' Cold drinks aggra- 
vate the pains, and therefore every thing administered should be luke- 
warm. It is best to give the children nothing but mucilaginous 
broths and demulcent drinks ; those at the breast bear very well the 
wet-nurse's milk ; in artificially-reared children cow's milk produces 
\dolent pain, and for this reason should not be administered. Opium 
is the sovereign remedy in dysentery, and the safest method of apply- 
ing it is in the form of clysters, but in this, unfortunately, we are 
often interfered with by the tenesmus. In such cases the pencilling 
of the mouth with laudanum, spoken of in the treatment of intestinal 
catarrh, will then have to be resorted to. I, however, never yield to 
the assurance on the part of the attendant that it was not possible to 
inject the medicine, but always try myself to administer the clyster, 
which I usually make of a drachm or two of some mucilaginous sub- 
stance, with one drop of laudanum, and I often succeed in it, although 
the existing circumstances were not encouraging. Very good efi'ects 
are also derived from the combination of calomel and opium. For 
example, to a child one year old, I give the following : 

^ . Calomel gr. ^, 
Op. pur. gr. ^V, 
Sack. alb. gr. v, 
Dent. tal. dos. n. viii, 
S. one powder every two hours. 

Vegetable astringents, nitrate of silver, and alum, are useful only 
after the pains have been mitigated, and in the chronic stage. 

(9.) Intussusceptions. — By intussusception, or invagination of the 
intestines (also called volvulus), we understand a slipping of one piece 
of the bowel into another, after the manner that the finger of a glove 
is reflected upon itself and shortened in pulling ofi" a tightly-fitting 
glove. 

Pathological Anatomy. — Not all invaginations, by any means, 
which are found in the infantile cadavers, were diseased conditions dur- 
ing life ; most of them indeed, having occurred in the agonies of death, 
show no trace of inflammatory reaction, may be disengaged with the 
greatest ease, and may be seen in many places at the same time ; but 



164 DISEASES OF CHILDREN. 

these occur only in the small intestines. Singularly enough, they are 
found only in perfectly healthy intestines, not in the autopsies of chol- 
era, flux, typhus fever, or peritonitis, although they are seen also in 
children who have succumbed to cerebral diseases, and seem to be the 
effects of an unequal innervation of the muscular coat of the intestines, 
which manifests itself preeminently in articulo mortis. However, there 
is also a long list of instances where, even in children under one year 
of age, invagination, Nvith all its results — intestinal stenosis, intestinal 
haemorrhage, stercoraceous vomiting, rapid collapse, etc. — occurred, 
and as a rule terminated in death. The pathological displacement of 
the piece of the bowel is the same in both kinds of invagination. 

Every invagination consists of three continuous portions, lying 
upon each other, of which the outer and middle have their mucous sur- 
faces, the middle and inner their peritoneal surfaces, in contact, as may 
be readily seen from the accurate drawing, PI. III., Fig. 3 B. The ex- 
ternal layer, or wall, c c, Rokitansky calls the sheath, or the intus- 
suscipiens ; the innermost one, a «, the advancing ; the middle, h 5, the 
protruding tube, and both together the intussusceptum. Between the 
advancing and protruding tube the flexed, conically-folded transverse 
section of the intussusception is found, which exercises a particular in- 
fluence upon the shape of the invagination. The dragging of the mes- 
entery serves to explain the reason why the invaginated intestinal 
piece never runs perfectly parallel into its sheath, but always presents 
a curve, and of its orifice not l}"ing in the axis or centre of the sheath, 
but always eccentric, because it follows the course of the mesentery 
inflected along with it, and for this reason also the orifice of the intus- 
susceptum (c?) is never round, but distorted into a slit. 

The enlargement of the invagination is brought about by the 
mouth of the volvulus {d) forming the fixed point, while the sheath 
Sit c c invaginates itself more and more. 

The cause of a volvulus is difficult to explain ; the intruding intes- 
tinal piece is probably more strongly contracted and has a more active 
peristaltic action than the wider, overlapping . piece of the bowel. 
This circumstance seems to be sustained by the fact that the process 
is almost always preceded by protracted diarrhoea, by which the over- 
lapping portion is probably catarrhally weakened, while the intruding 
portion has a normal mucous membrane and acts normally. 

As infallible effects of invagination, we have disturbances of the 
circulation in the invaginated mesentery, oedema, and hyperagmia of 
the invaginated gut, and inflammation and plastic exudation upon 
the peritoneal covering of the prolapsed and overlapping tube (a and 
b b). The oedema and inflammation of the invaginated portion may 
attain to such a degree, that the calibre of the intruding tube, at first 



DISEASES OF THE DIGESTIYE APPARATUS. 165 

still pervious, becomes completely occluded, and then no alvine matter, 
but bloody mucus only, will pass off per anum, and stercoraceous 
vomiting will take place. 

Generally the invagination takes place from above downward ; it 
frequently occurs in the large intestines, and when in the rectum may 
possibly be felt per anum. 

Intussusception proves fatal either from the peritonitis spreading 
over the entire intestines, or from gangrene of the invaginated piece. 

Symptoms. — ^^Tiile the calibre of the gut is still incompletely 
closed, the symptoms will not be particularly characteristic, but when 
total stenosis has once taken place, then the well-known signs, as in 
strangulated hernia, supervene. The invagination of the gut by itself, 
even without total constriction, always gives rise to the most violent 
colic-pains, conjoined with which the abdomen soon becomes tym- 
panitic. In some instances, an oblong tumor may be felt, which is 
regarded by many authors as the invaginated portion of the bowel, 
but it much more probably consists of alvine masses, which have be- 
come arrested at the volvulus. The patients are generally consti- 
pated, although diarrhoea may also occur, and in many cases large or 
small quantities of hlood may pass with the stools. The latter may 
be looked upon as the most constant and pathognomonic sign of the 
complete form of the condition. The vomiting of every thing par- 
taken of is almost equally constant, attended, sooner or later, by 
a yellow or greenish gastric mucus. The patients sink quickly into 
a state of collapse, with an expression very much like that of 
cholera patients, and death, as a rule, takes place on the third or 
fourth day. 

A favorable but very rare termination is in general adhesions of 
the invaginated portions of the bowel, and subsequent sloughing off 
of the gangrenous piece. Some authors assert that the symptoms 
occasionally abate, even without gangrene and sloughing of the con- 
stricted portion, that the calibre of the gut increases, and the inva- 
gination may thus remain fixed. In that case, however, the canal is 
ever afterward constricted, presenting a more or less permanent 
obstacle to the passage of its contents. A chronic, relapsing state of 
inflammatory swelling is the result of this condition, w^iich may 
readily develop itself into enteritis and cause new intussusceptions. 

Treatment. — The theoretic suggestions of Roldtansky to try in- 
jections by air or aspirations by means of a suction-pump, before the 
volvulus has become firmly fixed by exudation, will always remain 
theoretic. All remedies which cause an increased peristaltic action 
may do as much harm as good, for although the volvulus may, it is 
true, possibly become disengaged, yet in the reverse motions it may 



166 DISEASES OF CHILDREN. 

also become much aggravated, and a commencing and fortunate ag- 
glutination may thus be torn apart and interrupted. For the same 
reason neither mild nor drastic cathartics should be given, and still 
less emetics. The renowned application of mercurius "vdvus is at 
least harmless and often proves useful ; for the diminishing, con- 
stricted calibre of the oedematous invaginated gut may be thereby 
mechanically rendered a little pervious. 

The most rational treatment seems to me that suggested by 
Pfeufer^ and often already successfully carried out. It consists in ab- 
solute rest, strict diet, and in the production of narcotism by opium 
so as to effect a complete arrest of the peristaltic action, while ag- 
glutination takes place all around. Gastrotomy has also been suc- 
cessfully performed for the rehef of this affection, notwithstanding its 
very great dangers. 

(10.) iNGTmsTAL Heknia {JSemia Inguinalis), — Since umbilical 
hernia has already been treated of on p. 62 in connection with the 
diseases of the navel, and since crural hernias in children hardly ever 
occur, it only remains for us to speak of inguinal hernia. 

Inguinal herniee in children are, in the great majority of instances, 
external and generally congenital, though not congenital in the strict 
sense of the term, but acquired in the first few days of life, by the 
early action of the abdominal muscular pressure. One or several 
knuckles of intestine may be forced through the stiU open processus 
vaginalis peritonei into the scrotum in the male, and the labile ma- 
joris in the female. The prolapsed viscera lie in contact with the free 
surface of the testicle, a condition not seen in any acquired hernia. 

An oval, not strictly circumscribed, soft, compressible tumor is 
found in the groin, reaching from the external ring into the scrotum, 
which, by a uniform, slightly rotatory pressure, may be removed with- 
out any difficulty. It is not easy to distinguish the testicle, but on 
very careful examination it will be found to lie above and behind the 
tumor. Flatulence, pressure of straining at stool, crying, and cough- 
ing, reproduce the replaced rupture. In girls, where the rupture is 
called " external labial hernia," one or the other labia majoris exhibits 
a soft, oblong tumor, which, though presenting similar characteristics 
to the congenital inguinal hernia of the male, never becomes so large, 
and is less frequently met with. Here the rupture originates by a 
portion of the intestines, or in very rare instances the ovary, forcing 
itself into the inguinal canal {canalis ligamenti rotundi) destined in 
the female foetus for the passage of the round ligament, which is open 
at its origin, but which before birth usually becomes closed through- 
out. According to V. Ammon, a distinct peritoneal fold rarely forms 
the covering for the hernial sac in this rupture. 



DISEASES OF THE DIGESTIVE APPARATUS. 1^7 

The contents of congenital inguinal hernia almost always consist 
of one or several knuckles of intestine, very rarely of omentum. At 
first the rupture is small, of the size of a pea, but soon grows larger 
and protrudes into the scrotum, inducing shortening and straighten- 
ing of the canalis vaginalis. Sometimes some serous fluid is effused, 
and then we have a hydrocele superadded to the inguinal hernia. Vio- 
lent attempts at reduction, perhaps, also may be a cause of inflamma- 
tory and even plastic exudation, in these cases producing filamentous 
adhesions between the prolapsed intestines and the testicle, when of 
course it becomes totally impossible to reposit the hernia. Strangu- 
lations, however, are extremely rare ; yet, when such a rupture tem- 
porarily becomes hard, painful, and apparently irreducible, by the aid 
of a warm bath, or still more easily by the aid of chloroform, reduc- 
tion may invariably be accomplished. 

If the rupture has already acquired a considerable size, and the va- 
ginal canal has become considerably distended, it will protrude again 
immediately after it has been reduced, and will only remain in the 
peritoneal cavity so long as the child is in the horizontal posture. 
These children are extremely liable to become excoriated, and it is 
as difficult to prevent the integumentary abrasions as to cure them. 
In the examination of a young child for inguinal hernia, the testicle 
should first be found, because a testicle that has but just passed 
through the internal abdominal ring, in a case of retarded descensus 
testiculi^ represents a tumor analogous to a commencing hernia. As 
features distinguishing this condition from hydrocele, we may men- 
tion the reducibility of the tumor, in many instances attended with 
a gurgling noise, the absence of transparency, and the absence of 
fluctuation. The examination is carried out in this manner : The 
child is laid upon its back, an effort is carefully made to reduce the 
tumor, and, when that has been accomplished, the little finger is in- 
vaginated in the scrotum. It is next passed on upward toward the 
ring, the aperture is sought for, and, when found, its position and ex- 
tent are ascertained with the utmost ease. 

If we take a final resume of the most important varieties of con- 
genital inguinal hernia, we find — 

In respect to the time of origin : 

(1.) Hernia canalis vaginalis congenita (rarer form). 

(2.) Hernia canalis vaginalis mox post-partum acquisita (more 
frequent form). 

In respect to the difference of the sex : 

In boys : 

(1.) Hernia canalis vaginalis testiculi congenita. 

In girls : 



108 DISEASES OF CHILDREN. 

(2.) Hernia ccmalis Ugamenti rotundi congenita. 

In respect to the complications : 

(1.) Hernia inguinalis congenita cum hydrocele. 

(2.) Ilernia inguinalis congenita cum adhcesio7ie testiculi ad iti- 
testina. 

Treatment. — Most of the inguinal herniae disappear spontaneously 
mthout truss or bandage. This is effected by the best and simplest 
of all compression of the inguinal canal, viz., by the augmentation of 
the adipose tissues in the child. Good nutrition, attention to the 
bowels, and the avoidance of too great and lasting restlessness, suf- 
fice, as a rule, to cure this defect. If the precaution is only taken to 
reduce the hernia while the child is asleep, it will be of little conse- 
quence if it is prolapsed for the rest of the day. The reduction is 
very easily accomplished by the nurse, at the time the child is being 
put asleep, by pressing her hand firmly, but gently, over the tumor. 

I have only seen good effects from the use of trusses in children 
over one year of age. In very young children it is extremely difficult 
to apply the truss, and in many instances it is injurious. In the first 
place it is necessary to have three trusses, in order to have a dry truss 
every time one gets soiled and wet from the fseces and urine ; and, be- 
sides, if the child thrives, the old trusses in eight to ten weeks will be 
found to have become too small and useless, and must be replaced 
by three new ones, thus, perhaps, requiring a dozen. Furthermore, 
it is almost impossible to protect the child from becoming excoriated, 
and the parts that have once become chafed require several days to 
get well, leaving a new epidermis, which is usually soon destroyed 
again when the pressure of the truss is reapplied. Lead and zinc 
ointments, as well as repeated washings with cold water, or mth wa- 
ter and brandy, do, indeed, seem to have a favorable influence in ren- 
dering the skin less prone to abrasion, but they rarely prevent it al- 
together. In lean children it is totally impossible to apply the truss, 
because it can never be properly secured. "When, therefore, appre- 
hensive parents absolutely desire a truss to be applied, they should 
be previously admonished of its great expense, and of the probable 
bad effects which result from its use. I usually cover the herniae w^th 
a piece of adhesive plaster, or order some harmless ointment to be 
rubbed in upon them, and insist, in addition, upon the utmost cleanh- 
ness, good attention, proper food, and see that the bowels act regu- 
larly. By these means I have already seen many children cured. 
The more rapidly the deposit of adipose tissue takes place in the child, 
the more surely will the hernia be retracted, and permanent closure 
of the vaginal canal secured. 

(11.) FissuEA Ani. — Nurslings and children of all ages suffer 



DISEASES OF THE DIGESTIVE APPARATUS. 169 

sometimes from intense pain about tlie anus, which comes on at every 
attempt at defecation, and is due to a small fissure of the anus. 
Children so aifected are always constipated, and the fissure has prob- 
ably originated from the violent efforts of pressing out the hard fceces. 
Xow and then the firm, dry faeces are stained with blood, and, after 
defecation, a few drops of blood flow from the fissure, which is so 
painful to the child that it screams aloud. It is necessary to observe 
that these rents of the anus cannot be seen by a superficial inspec- 
tion ; so that, in order to discover them, it is necessary to thoroughly 
separate the nates, and to examine fold after fold of the mucous mem- 
brane. They are very small, sometimes not more than from one to three 
millimetres in length, and differ but little in color from the rest of the 
reddened mucous membrane of the anus. The pains come on almost 
always during, and directly after, defecation, but seem to be very se- 
vere, if we may judge from distorted features, a general trembling, 
and reflex movements of the whole body of the child. 

Treatment. — It is necessary, first of all, to relieve the constipation, 
which is best accomplished by the administration of a half to a whole 
teaspoonful of the watery extract of rhubarb. The method advocated 
by Trousseau^ of gi\Tng clysters containing 3j of ext. rhatany, I 
have not found satisfactory, as the introduction of the clyster itself 
causes the most intense pain. I cauterize these fissures with lunar- 
caustic, which is also tolerably painful, but it is only required once, 
whereas those clysters have to be repeated frequently. I also pay 
special attention to the bowels, with a view to prevent the fasces from 
becoming hard. Diarrhoea, also, ought not to be neglected in this 
aff'ection, for the diarrhoeal discharges likewise hinder the healing of 
the fissures. 

(12.) Polypi of the Rectum. — These polypi occur but very 
rarely, though they are perhaps sometimes overlooked. The record- 
ed cases of this aff'ection in children have occurred in those who have 
passed the second year of life. 

A small and at other times a larger amount of • haemorrhage from 
the rectum, either with, or immediately after, defecation, is the prin- 
cipal symptom. In girls, who are near the age of puberty, this is 
readily misinterpreted for commencing menstruation. But the men- 
strual stains may be easily distinguished from those produced by 
haemorrhage from the rectum, by the circumstance that the former are 
almost always to be found on the anterior part of the linen, while the 
latter are almost exclusively confined to the posterior part. 

The evacuation of the faeces is always painful and difficult, the 
polypus during that act occasionally protruding through the anal 
opening, but quickly retracting when the straining ceases. In explor- 



170 . DISEASES OF CHILDEEN. 

ing the rectum by the finger, a painful operation, the polypus is felt 
to be situated very near the anus. This malady has, in the majority 
of cases, a tendency to spontaneous cure, resulting from the polypus 
becoming more and more pediculated, and finally torn off during a 
difficult defecation. The pol}^us is usually of the mucous variety. 

Treatment. — The removal of the polj^us is readily accomplished, 
if, directly after a defecation — when it descends outside the anus — it 
is caught and pinched off with the finger-nails, or its pedicle tied. In 
order not to have to wait too long for an evacuation, a dose of senna, 
or some other cathartic, may be administered to the child a few hours 
before the aj^pointed time for the operation, because, by the tenesmus 
thus produced, the jDolypus will most certainly be protruded, and will 
remain out an unusual time. 

(13.) Peolapsus AjSTI. — Two conditions are described under the 
name of prolapsus of the anus, differing considerably from each other, 
namely (1), a simple protrusion of the lower folds of the mucous 
membrane, and (2), an invagination of the upper part of the rectum 
into the anus, which makes its appearance external to the anus. 

The rectum, as is known, may be di\-ided into three portions, an 
upper, middle, and lower (PI. III., Fig. 4, a, ^, e). The upper por- 
tion joins the sigmoid flexure, and, hke it, is covered by peritonaeum, 
has a cylindrical form, and runs from above downward, and slightly 
from left to right. This portion forms almost half of the entire rec- 
tum, and extends from its junction with the sigmoid flexure to a 
line where the peritoneal covering ceases (PI. III., Fig. 4, No. 3). 
Posteriorly the rectum loses this covering higher up than it does an- 
teriorly, where it is continued to a point opposite the third sacral 
vertebra. The middle portion (b) begins where the peritonseum 
leaves the rectum, and where it is adherent to the sacrum by loose 
cellular tissue only, and joins the bladder and prostate in the male, 
and the vagina in the female. This portion is remarkable for the 
strength of its longitudinal fibres, while its circular and transverse 
are but imperfectly developed. In constipation, it may become enor- 
mously distended, and harbor large quantities of hard, feculent mat- 
ter. The tliird portion (c) is the shortest ; it reaches from the pros- 
tate gland do^vnward to the anus, and possesses a thick layer of trans- 
verse muscular fibres, the two sphincters ani. 

Either this sphincter, or lowest part of the rectum, may become 
simply everted, and present a bluish-red or pink colored puffy mass 
mth a central opening, or the middle section of the rectum (b) may 
become invaginated in the lower and hang down from the anus, a 
pink-colored or li\id mass several inches in length, the color depend- 
ing upon the degree of its constriction by the sphincter. A simul- 



DISEASES OF THE DIGESTIVE APPARATUS. 171 

taneous eversion of the sphincter portion and invagination of the 
middle portion do not seem to happen. In the simple eversion of the 
sphincter portion, the examming finger may force its way into the 
central opening, and* will generally reduce it, but, in the prolapsus of 
the middle portion, the finger or the probe may pass alongside of the 
prolapsus for one or even two inches before reaching the upper 
flexion. 

Etiology. — Eversion of the sphincters, or, at least, a partial pro- 
lapsus of their mucous membrane, occurs extremely often in small 
children. It will generally be found that diarrhoea has preceded for 
some time, and that, as a consequence, the mucous membrane has 
become gorged, puQj, and flaccid, and the sphincters enfeebled. 
Persistent constipation may also give rise to prolapsus, the rectum 
seeming to be forced out by the hard and large fecal masses. In- 
vagination of the middle portion, however, occurs oftener from this 
cause than eversion of the lower. In young pups afilicted with the 
so-called distemper, large invaginations of the middle portion of the 
rectum are frequently observed. 

The 2^^^og7iosis is favorable in both these conditions, if the children 
are in other respects healthy and well nourished, and a radical cure 
may be achieved ■without an operation, but in atrophied children it is 
unfavorable. 

Treatment. — As regards the general treatment it is manifest that 
astringents should be employed in prolapsus from diarrhoea, and that 
nuld laxatives are indicated in prolapsus resulting from constipation. 
To the former class, opium, the mucilaginous and vegetable astrin- 
gents, and the nitrate of silver and alum, belong; to the latter, rheu- 
barb and the neutral salts in small doses. Castor-oil is very difficult 
to administer to small children, who usually refuse to swallow it, or 
reject it by vomiting. 

The reduction of the prolapsus is less a question how to do it than 
when it is to be performed. It is of first importance that it be reduced 
at once, and we should so instruct the parent or nurse, giving at the 
same time the rules for doing it. These comprise the laying of a piece 
of lint, smeared with simple cerate, upon the prolapsed bowel ; then, 
seeking the central opening with the finger, thrust it well into the 
bowel, carrying with it the prolapsed portion. After the prolapsus 
and finger have thus found their way into the anus, the finger is slowly 
withdrawn with rotatory motion. The piece of lint may be readily 
pulled out without danger of inducing the prolapsus anew. In winter, 
or where ice is readily at hand, it is very useful to slide a small round 
piece of ice into the prolapsus before the reduction is undertaken, and 
then to reposit the protruded bowel with the ice. 



172 DISEASES OF CHILDREN. 

In atrophic children the prolapsus will always recur, no matter how 
often it is reduced, though cauterized or burned. In well-developed 
children this treatment is generally sufficient to cure the affection, but, 
when the disposition to prolapsus has existed for a long time, a few 
longitudinal apphcations of lunar caustic, or faming nitric acid, may 
become necessary. I have never yet been compelled to use the 
actual cautery in this affection. 

In order to prevent the straining to which some children are ad- 
dicted from mere habit, it is advisable to set the chamber upon a foot- 
stool, so high that the children will not be able to reach the floor 
with their feet, a position which ^Yl[\ prevent them from exercising 
any very great abdominal pressure. Experienced nurses know the 
value of holding children, thus afflicted, suspended in the air during 
defecation, and at the same time of compressing and supporting the 
anal orifice as a means of preventing the prolapse of the bowel. 

(14.) Malfokmations of the Anus aj^b Rectum. — We have 
two kinds of malformations of the anus ; (a) a constriction and (b) a 
closure. 

(a.) Constriction of the Anus. — A moderate degree of constriction 
rarely produces marked symptoms so as to require surgical aid. This 
is especially true of children during the first year of life, because their 
f^ces in the normal condition are never solid, but always in a semi- 
sohd state and formless. The condition becomes troublesome only 
when constipation supervenes. Evacuation of the bowel then becomes 
difficult or impossible, and tympanitis and even symptoms of in- 
testinal stenosis appear. If the hard alvine matter can be softened 
by frequently-repeated clysters, it w^ll then be discharged, and all the 
symptoms will disappear. The same result may be obtained by laxa- 
tives, but their action _ in these cases is always attended by severe 
colic-pains. 

Sometimes, however, children are born with such a degree of con- 
striction of the anus, that even the discharge of the meconium is 
delayed and attended with difficulty. It is sometimes such as to 
render it impossible to introduce an ordinary probe into the rectum. 
Here, of course, a small surgical operation is indispensable, and is 
best performed by introducing a grooved sound, dividing the con- 
stricted anal opening upon it with the knife, and then dilating it 
to one-third or one-half of an inch. Pledgets of lint, smeared with 
cerate, must then be introduced into the wound for several weeks, 
in order to prevent a too early closure ; this, with the passage of the 
faeces several times a day, prevents the formation of contracting 
cicatrices. 

{h.) Occlusion of the Amis {Imperforatio Ani). — In order to 



DISEASES OF THE DIGESTIVE APPAKATUS. 173 

tliorouglily compreliend the pathological history of this condition, it 
is necessary to consult embryology. We are there informed that, at 
a very early date of embryonic life, a connection exists between the 
bladder and rectum, by which the former serves as a cloaca, and that 
the rectum originally terminates in a cul-de-sac, that this cul-de-sac 
extends downward into the lesser pelvis, where it meets a similarly 
blind projection of the external integument, the rudiment of the anus, 
and that not till a mutual fusion of both these sacs has taken place, 
and disappearance of the opposing terminal sac-wall, is a communica- 
tion established between the rectum and anus. 

The following arrests of development may occur, systematically 
dehneated on PI. III., Figs. 5-9. 

(1.) The rectum is fully developed, but in the natal fold, where the 
anal depression is usually found, nothing of the kind is to be seen, but 
the blind extremity of the rectum reaches to the cutis, which it is 
unable to perforate. This is the simplest and most favorable kind of 
imperforatio or atresia ani. The meconium that accumulates after 
the delivery of the child distends the rectum, bulges out the integu- 
ment beneath, at the spot where the rectum terminates, and a simple 
crucial incision is sufficient for the formation of an anus (Fig. 5). 

(2.) In this condition the anal depression has developed itself 
normally, but is unable to reach the blind end of the rectum, because 
it has either been arrested in its growth (Fig. 6), or it terminates in 
the vagina (Fig. 8), or in the bladder (Fig. 9). In these cases the 
simple inspection of the anus supphes no explanation, for this part is as 
normally formed as in every healthy child. The non-appearance of the 
meconium during the first twenty-four hours, restlessness of the child, 
a tympanitic and distended abdomen, and refusal to take the breast, 
usually first call the nurse's attention to the state of the bowels. 
Relief is sought in clysters, and the discovery is made that the pipe 
of the syringe either does not go in far enough, or, even when this 
difficulty does not exist, that the clyster is instantly returned. If the 
examination is now made with a probe or silver catheter, it will be 
found that the anal depression terminates in a cid-de-sac one or two 
inches deep. 

(3.) There is in this condition neither an anal depression or 
cul-de-sac, nor has the blind extremity of the rectum grown down so 
far as to be traceable, after birth, by an outward bulging of the 
integument (Fig. 7). In these cases, generally, no sign of an anal 
depression is observed in the fissure between the nates, and there is 
no guide by which to judge of the state of the rectum, the blind 
extremity of which terminates in the lesser pelvis at a distance of two 
or three inches from the integument. Sometimes a firm, compact 



17i DISEASES OF CHILDREN. 

cord runs from the sigmoid flexure to the cutis, wliich may be re- 
garded as a rudimentary rectum, and renders important services in 
searching for the blind extremity of the bowel. 

(4.) The rectum does not terminate externally, but in the vagina, 
bladder, or in one of the ureters, conjointly ^vith which an anal depres- 
sion may or may not be present (Figs. 8 and 9). In this condition the 
meconium is not absolutely retained, but passes off with the urine in 
one case, and by the vagina in the other. The diagnosis may be made 
with ease by examining the bladder with a silver probe or small cathe- 
ter, and by collecting the urine that contains the meconium ; and still 
more easily when the orifice of the rectum is discovered in the vagina. 
Various are the effects of this malformation. In cases where the rec- 
tum communicates with a ureter or with the bladder, the urine always 
becomes alkaline, constantly irritates the mucous membrane of the blad- 
der, and causes cystitis, atrophy, and death. But, when the rectum ter- 
minates in the vagina, it produces a disgusting infirmity, from the con- 
tinuous flow of the faeces, which are not retained, on account of the 
absence of the sphincters. The child is always soiled about the thighs 
and always emits an odor of fseces, yet it is by no means incapable 
of living. Instances have occurred where the rectum has been es- 
tablished by an operation, and then the connection between the bowel 
and vagina became occluded. 

(5.) Finally, there are cases in which the rectum does not exist at 
all, or only in a rudimentary form. A portion of the large intestine is 
only jDresent, and that terminates in the umbilical region, as a result 
of the embryonical ductus omplialo-entericus having remained open, a 
condition that has been denominated ayius pvmternaturalis or Ecto- 
pia cmi. 

Treatment. — The treatment, naturally, can only consist of an op- 
eration. In the cases spoken of in sec. 1, the operation will be, as 
already indicated, to make a simple crucial incision through the out- 
ward bulging integument, when the meconium vriW. be speedily evac- 
uated. A pledget of lint with cerate is introduced into the wound 
after every evacuation from the bowels, for the first few weeks, in order 
to prevent union of the lips of the wound. 

In the cases mentioned in sec. 2, a cautious attemjDt should be made 
to find and jDuncture the rudimentary rectum by the aid of an ordinary 
large trocar, such as is commonly used in paracentesis abdominis. 
The soft, fluctuating tumor will materially aid us in discovering the 
cloaca. An elastic catheter cut off at the top is then introduced 
through the trocar canula, and through it warm water is injected three 
or four times daily to liquefy the faeces. After several days the cath- 
eter should be replaced by one of larger size, and this practice is 



DISEASES OF THE DIGESTIVE APPARATUS. 175 

persevered in till the defecation can take place regularly and without 
any difficulty. Generally the sphincters of the anus exercise their 
functions tolerably well, but a disposition to constriction often remains, 
which must be combated by the use of bougies. 

In the form of atresia ani described in sec. 3, a crucial incision to 
the depth of one inch must first be made over the spot where the anus 
normally occurs ; the blind extremity of the rectum may then be sought 
^vith the finger, and, when found, is treated with the trocar in the same 
manner as in the cases described in sec. 2. That these operations fre- 
quently prove fruitless, and even when the rectum is opened often ter- 
minate fatally, might be anticipated from the feebleness of the new- 
born child. 

In cases where the rectum communicates with the bladder, the 
effort must likewise be made, as rapidly as possible, to secure a passage 
for the fgeces by some other channel, because, if not done, a fatal re- 
sult is inevitable. But, in the cases where the rectum terminates in 
the vagina, there is less urgency for an operation, as this condition 
may be tolerated for a very long time ; indeed, instances are known 
where children have grown up with this malformation, without any 
surgical assistance. As soon as the child has acquired sufficient 
strength, an attempt should, however, be made, even in these cases, 
to establish a proper anus. The communication with the vagina 
will then either become occluded of itself, or it may be very easily 
remedied by a small operation. 

If, in such cases as are described in sees. 2 and 3, it be not possible 
to find the rectum, then, according to the laws of surgery, an artificial 
anus should be made in the left lumbar, or in one of the inguinal re- 
gions. That children may recover from such an operation has often 
been sho^vn, but whether they thrive and grow up I am not able to 
say. At least, I have never seen an adult in whom an artificial anus 
had been established in any of these places in the early days of life. 

(15.) Infectious Diseases w^ith Peedominating Localization 
UPON the Intestinal Canal. (A. Typhus Ahdoininalis.) — Abdomi- 
nal typhus is much more frequent in children than is commonly sup- 
posed, but the diagnosis in many cases cannot be made with certainty, 
and, on this account, many physicians attribute to children great resist- 
ance against this disease. Their liability to infection, if such can be 
assumed, is an extremely small one, and is not at all to be compared 
with the other. infectious diseases, measles, scarlatina, and pertussis. 
While it often happens that the children of several families in one 
house are simultaneously attacked by typhus fever, usvially of a mild 
form, still it more frequently occurs that only one child out of a nu- 
merous family is seen to fall sick with it, all the rest remaining well, al- 



176 DISEASES OF CHILDREN. 

though all have occupied the same room, and none of them have been 
protected by pre\ious fever. Typhus fever is extremely rare in children 
before the completion of the first year of life ; still individual cases are 
found recorded of nurslings who perished by this disease, but it is ob- 
served that no typhous intestinal ulcerations^ simply infiltration of 
Peyer's patches and of the mesenteric glands, are sjDoken of in the 
reports of the post-mortem examinations afforded by these cases. In 
the second year of life, and after the completion of the dentition in the 
third year, abdominal typhus becomes extremely frequent, and is at- 
tended by tolerably characteristic symptoms, and from this age on- 
ward it may occur at any age and at any season of the year. 

As the plan of this treatise presupposes a thorough knowledge of 
special pathology and therapeutics derived from other sources, hence 
only the deviations peculiar to the infantile age can properly come 
within its scope. Nor does a critical examination of the present pre- 
vailing opinions regarding contagious diseases, and the connection of 
the local with the general affection, belong to it. But this much must 
be said in this connection : (1.) That the conditions found in the ali- 
mentary canal do not stand in exact relation to the general disease ; and 
(2.) That no qualitative nor quantitative alterations have ever yet 
been found in the blood of typhous patients. The changes in the 
blood of typhous patients, who have been ill for many weeks, are the 
effects of protracted disturbances in the textural metamorphosis, and 
of the circulation ; and the so-called typhous blood, by which a dark, 
violet-colored hquid blood, with soft, loose coagulas, is ' understood, is 
not invariably found in the tj-phus cadavers, but yet in the cadavers 
of most patients whose diseases were combined with disturbances of 
respiration and assimilation. 

Post-mortem Appearances. — ^In general, a first and a second period 
can be distinguished m the typhus corpse. 

If death takes place in the first period^ the typhous morbid 
changes will only be found in the small intestines, in the mesenteric 
glands, in the spleen, and upon the bronchial mucous membrane. — 
The cadavers are not emaciated, have deep-blue post-mortem spots, 
and the muscles are dry and dark colored. The brain is firm and dry. 
The bronchial mucous membrane is reddened, swollen, and everywhere 
coated with a tenacious, yellowish-white mucus, so that in some 
places the bronchi of the third order are completely filled up with it. 
The infallible consequences of this overfilling of the bronchi with mu- 
cus, especially posteriorly and inferiorly, are disturbances of circula- 
tion in the pulmonary organs, hj^oostasis, and ultimately splenization. 
The heart is extremely feeble, contains very loose coagulae, and its mus- 
cular structure at some places is blanched. These pale spots exhibit, 



DISEASES OF THE DIGESTIVE APPARATUS. 177 

under the microscope, commencing fatty degeneration. The spleen is 
enlarged, and the enlargement affects particularly its long diameter. 
Its capsule is tensely distended, its structure very dark and soft, and 
often of a semi-fluid consistency. 

The abdomen is distended, the bowels are tympanitic, and con- 
tain a large quantity of intensely-offensive fluid ; almost the whole 
mucous membrane of the small intestines is in a state of acute 
catarrh, and Peyer's patches, as well as the solitary follicles, are pe- 
culiarly infiltrated. The hypertrophy of the glands just mentioned 
is produced by a deposit of a grayish-white medullary mass, which 
principally fills up and swells the capsule of the glands, but in- 
volves also the submucous and even the mucous tissue itself. The 
morbid changes and course of these infiltrations in children deviate 
somewhat from those observed in the adult. While the great majority 
of typhus cadavers of the adult display ulceration of the glandular 
patches, in children this is only an exceptional occurrence, for the in- 
filtration, in most of these cases, seems to undergo a retrograde meta- 
morphosis, or at least a simple bursting of the capsule and evacuation 
of its contents without any cicatrization. Although, in rare instances, 
true cicatrization or ulceration has been found, they are nevertheless 
but isolated instances in which one or more patches only have been 
implicated. The majority of Peyer's patches always stop at the stage 
of the brain-like infiltration, and this, in fact, also explains the reason 
why intestinal hsemorrhage and perforations are so extraordinarily rare 
in children. The younger the child, the less frequently are ulcerations 
met with. I have never yet found them in children under four years, 
although I have dissected many children, of from two to four years of 
age, which died from undoubted typhus fever. 

The mesenteric glands become affected in exactly the same man- 
ner as Peyer's patches. They enlarge to three or four times their nor- 
mal size, and, when cut into, are seen to be yellomsh gray and brain- 
like. Their size appears to depend upon the amount of infiltrating 
material deposited into them ; Peyer's patches are to be found oppo- 
site the ileocsecal valve ; so also the mesenteric glands opposite this 
valve are most hypertrophied. 

If the cadaver of a child which died in the second stage be dis- 
sected, the first thing that will attract the attention is the extreme 
emaciation. The sldn is pale and flabby, the post-mortem spots are 
not so intensely violet, the muscular system is pale and oedematous, 
and infiltrated with serum. The integument often exhibits bed-sores, 
pustules, sudamina, and ecchymosis ; sometimes the loAver extremities 
are somewhat dropsical. The parotid gland may be swollen and per- 
meated by purulent sinuses. Perichondritis and necrosis of some 
12 



178 DISEASES OF CHILDREN. 

of the laryngeal cartilages are sometimes observed in the lar3Tix; 
the lungs reveal a still greater amount of splenization than in the 
first period, and the bronchi are filled with mucus. The spleen is 
swollen and corrugated, the mesenteric glands are enlarged, and 
abscesses are sometimes formed in them. Peyer's patches and the 
solitary follicles are slightly tinged with a grayish pigment ; the cap- 
sules are mostly ruptured, giving the whole glandular surface a reticu- 
lated appearance ; and when, in older children, solitary ulcerations 
have occurred, they will be seen undergoing cicatrization. If the chil- 
dren have succumbed to pyr«mia, the well-known purulent effusions and 
embolic formations will be found in the serous sacs and parenchyma- 
tous organs. If they have perished from anaemia and scorbutis, marked 
serous effusions in the cavities of the body and in the subcutaneous 
tissues will be found. In scorbutis the morbid condition of the gums 
will have become superadded. The brain, in contrast to the first pe- 
riod, is extremely moist and soft, and is with difficulty removed entire 
from the cranial cavity. The rarity with which ulcerations of Peyer's 
patches occur makes it easy to confound this pathological condition 
mth that found in enteritis folhculosa. But the hypertrophy of the 
spleen and the state of the lungs are sufficient to distinguish typhus 
fever from follicular enteritis. 

Symptoms. — As may already be inferred from the description of 
the post-morte'in appearances, the morbid alterations and destruction 
which typhus fever brings about in the infantile organism are not so 
decided as in the adult ; and, correspondingly, the symptoms are 
usually also less intense and threatening, and the prognosis in general 
favorable. The symptoms are seldom so violent and characteristic 
that the diagnosis of typhus fever may be formed with certainty at 
first sight, as an experienced observer may usually do when he 
approaches the bedside of an adult patient seriously sick with it. 
The diagnosis is very liable to vacillate between t}^hus fever and 
acute hydrocephalus, and upon this difficulty in the differential 
diagnosis many of the recoveries from supposed acute hydrocephalus 
rest. In most of the cases, however, children have so mild a form of 
typhus fever, that it is confounded Avith gastrocismus or dentition 
troubles, and consequently less apprehensive parents do not seek any 
medical assistance at all. Physical diagnosis furnishes little, if any, aid 
in this mild typhus fever of children. The spleen does not become mate- 
rially enlarged, the abdomen is not much distended by gas, and the 
bronchial catarrh attains to no alarming degree. The diarrhoea is 
moderate, the children are quiet, do not complain of pain, and sleep a 
great deal. The marked and protracted lassitude, the continued loss 
of appetite, and the tedious convalescence, during which the hair al- 



DISEASES OF THE DIGESTIVE APPARATUS. 179 

Trays falls out, and is at first replaced by a thinner, lanugo-like crop, 
are the most characteristic sjnnptoms of a lingering febris typhoides, 
wliich in Munich is popularly called " mucous fever." 

Yet it cannot be denied that individual children, especially after 
they have completed the first dentition, may display very severe 
and complete symptoms of typhus fever, and it is therefore necessary 
to subject them to a special analysis. 

First of all, as regards the chronology^ there is no acute disease in 
which it is so difficult to decide the period of invasion as in typhus 
fever; nevertheless, this is usually easier in children than in adults, 
since their tenderer organism is much more violently disturbed by an 
infection, and its commencing action. And, besides, they are neither 
compelled by necessity nor occupation to struggle against the disease 
as long as jDOSsible, notwithstanding its growing severity, and there- 
fore their early symptoms are unmodified. The day on which the 
child loses its accustomed spirits, and lies down and falls asleep at un- 
usual hours, when followed by the more characteristic symptoms, is to 
be regarded as the commencement of tj^hus fever. The child some- 
times retains its appetite up to the same day, but usually it vomits the 
whole undigested meal at the end of a few hours, when the symptoms 
of typhus fever, as a rule, come on quicker and are severer than when 
no vomiting has taken place. T have never observed any distinct chills, 
and consequently can place no value upon them in deciding the day 
of invasion. \Vhen typhus fever develops itself during dentition, it 
will scarcely be possible to decide its commencing period, for here the 
almost physiological diarrhoeas and congestions of the head pass over 
very insidiously into the typhous symptoms. Typhus fever in chil- 
dren may, as respects its duration, run a course as irregular as it does 
in the adult, and therefore no definite conclusion can be formed, as to 
its course and duration, from the violent appearance of the first symp- 
toms. Some children recover quicker from an intense typhus fever 
than others do from a very mild, lingering febris typhoides. In gen- 
eral, however, it may be assumed that a child, which has recovered 
completely in less than three weeks without marked emaciation, has 
had no typhus fever^ nor even a febris typhoides^ because children 
affected by those diseases are retarded in their development and nu- 
trition for more than three weeks. 

The extent of febrile phenomena in children cannot be so readily 
expressed as in the adult, such as the pulse, temperature of the 
skin, and the amount of urine excreted. The restlessness of a 
t}^hous child interferes with the use of the thermometer to determine 
the temperature of its skin, because, as is well known, the instru- 
ment must be entirely surrounded by integument, and allowed to 



180 DISEASES OF CHILDREN. 

lie quietly for from fifteen to twenty minutes. It is, therefore, better 
to observe the warmth of the forehead, trunk, and extremities, with 
the hand, j^reviously warmed, no matter under what disease he 
may be laboring, and this kind of examination, practised a few 
hundred times, gives such an amount of skill, in distinguishing the 
different degrees of temperature, that thermometric measurements, 
always requiring a certain amount of time, and often totally impossi- 
ble, will be entirely unnecessary for any practical purpose. As to the 
pulse, upon whose condition and frequency in adults so great value 
is justly placed, it gives less positive indications in children. It is 
always extremely rapid, up to 160 and 170 beats in the minute with- 
out being attended by corresponding danger, or rendering the prognosis 
particularly unfavorable. During convalescence it may be compressed 
with the utmost ease ; in the mortal agonies it becomes uncountable 
and imperceptible. An intermittent pulse seldom occurs in children, 
and I do not remember to have ever met with a dicrotic pulse in chil- 
dren under ten years of age. 

Of the subjective febrile symptoms, the prostration, the excitability, 
and the lethargy, are always the most important. Hardly ever do 
children suffer any decided chills ; the head is always flushed, the eye 
heavy, and in patients greatly excited presents a pecuharly glistening 
appearance. The expression of the face is either that of apathy or of 
great excitability, or, in the most \dolent cases, of confusion. 

Very soon the assimilative functions assume an extremely unfavor- 
able condition. The loss of appetite, and the uncontrollable, profuse 
diarrhoeas on the one hand, and the urine, rich in excretive material, 
on the other, explain sufficiently the rapid emaciation of typhous chil- 
dren. I have often endeavored to extend, in the case of children, my 
investigations of the urinary substances, which, for years, I have carried 
out on a very extensive scale in adults. But all my efforts foundered 
on the impossibility of obtaining the urine which children under ten 
years of age pass in the twenty-four hours. Isolated opportimities for 
the investigations of the urine always showed in typhous children 2.5 to 
3.5 per cent, of solids. As, judging by the eye, they pass a tolerably 
large amount of urine, it may be fairly inferred that, in tyjDhus fever, 
children, as well as adults, lose a large quantity of urinary soHds. It 
is a remarkable fact that the emaciation progresses and only attains 
its climax when the appetite has already fully returned and the pa- 
tients are steadily convalescing. If sequelae, such as tuberculosis, 
scorbutis, phlebitis, in various cutaneous veins, or large abscesses, su- 
pervene, the child will often be reduced to a mere skeleton, but 
the prognosis need not on that account necessarily be assumed as ab- 
solutely desperate, for such children occasionally, manifest a wonder- 



DISEASES OF THE DIGESTIVE APPARATUS. 181 

fill resisting power, and finally, after many months, recover. After 
every intense typhus fever, children lose their hair almost completely. 
It returns slowly, first very thin and lustreless ; ultimately, however, 
it grows stronger, acquires its original color and fulness. In the usual 
milder forms, in which the prevailing typhous symptoms are only im- 
perfectly developed, the falling out of the hair is less marked. 

The most important alterations always take place in the digestive 
system. Anorexia is one of the most constant symptoms, usually 
comj)lete, but sometimes attended by peculiar longings, such as for 
rye-bread, fi'uit, etc., articles which, in fact, may be allowed the child 
without any great danger, so long as the precaution is taken not 
to indulge it with too large quantities at a time. Generally it plays 
with the food placed before it, carrying a little to the mouth from 
time to time, but, in most instances, does not swallow even that, but 
spits it out again, and so the craving for food is appeased. The ano- 
rexia lasts as long as the febrile symptoms continue, during which 
time the greatest difficulty will be experienced in supporting the 
children in any manner, fluid food being almost exclusively available. 
After a while the appetite returns, and in a few days becomes a rav- 
enous hunger, the indiscreet gratification of which often causes serious 
relapses. 

In children the tongue seldom becomes as dry as in the adult, be- 
cause they almost always sleep with the mouth shut, and thus the main 
cause of the dryness of the tongue is wanting. In most instances it 
is rather thickly coated, and the papillse are seen to be dark red, but 
in grave cases the characteristic brown, dry, furred tongue of typhus 
fever is present. 

The lips desquamate and bleed a good deal, especially in older 
children, who pick almost incessantly at them. The so-called sooty 
coating of the lips is the result, in this disease, of the blood drying 
upon their surface. The fetor of the mouth, which in adults is so fear- 
fully disgusting, is less intensely marked in children. 

The parotid gland occasionally swells up in typhous children, and 
is always to be regarded as a most dangerous symptom. It is 
not possible to say with any certainty whether all kinds of parotitis 
are of a metastatic nature, for the catarrh of the mouth may indeed be 
directly propagated to the Stenonian duct and even to the salivary 
gland itself. But the dangerous character of this complication and the 
fatal termination that ensues in most instances make it probable that, 
in the majority of cases the cause of the parotitis is an actual metas- 
tasis, and not a simple propagation of the catarrh. It invariably ter- 
minates in suppuration, and, if life continues sufficiently long, the gland 
undergoes purulent degeneration. In the cadaver a number of small 



182 DISEASES OF CHILDEEX. 

abscesses, of the size of pins' heads, are always found associated with 
larger ones. 

The morbid phenomena are usually ushered in with vomiting ; 
young children often vomit several times a day during the whole course 
of the disease, o'x^'ing to which, when unattended by diarrhoea, it be- 
comes extremely difficult to diagnosticate the disease under considera- 
tion from acute hydrocephalus. This obstinate vomiting is due to a 
profuse gastric catarrh, as is shown by the fact that the patients not 
only throw up the little fluid nourishment they consume, but also con- 
siderable quantities of mucus, through which they become rapidly 
atrophied and usually succumb to the disease. The vomiting which 
accompanies perforative peritonitis in the adult is rarely seen iu 
children, for the simple reason that the inducing cause, perforation of 
the intestines, scarcely ever occurs. 

The cibdominal pains and tenderness which accompany this disease 
in the adult are hardly ever complained of, and difficult to be elicited, 
in children under two years of age ; they occm* only occasionally in 
older ones, and are not ver}^ severe. The importance of gurgling in 
the cereal region^ which was formerly described as a pathognomonic 
symptom of typhus fever, has deservedly fallen into disrepute, for it 
is just as frequently found in every intestinal catan^h. 

The tympanitis attending those cases in which the ulceration is 
limited is not very great, and consequently its effects, such as impeded 
respiration, from the pressure of the diaphragm upward, pulmonary 
stenosis, and cyanosis, occur only in milder degrees. 

The intestinal evacuations differ in no res23ect from those in the 
adult. Diarrhoea is not usually jDresent during the first few days of the 
disease, but it always comes on later, though laxatives may not have 
been used, and constipating drinks may have been given ; from twenty 
to thirty dejections taking place during the day. A collection of all 
the stools evacuated in the twenty-four hom'S, in children, is of course 
altogether out of the question, but it may approximatively be stated 
that, according to the weight and space, typhous children discharge 
three or four times as much as healthy ones. The quantity dis- 
charged in the twenty-four hours does not always stand in relation to 
the number of evacuations ; some children discharge a larger quantity 
of typhous fseces in two or three stools, than others do in ten or twelve, 
the number depending entirely upon the irritabihty of the rectum. 

If the stools are very thin, they will be of a light-brown color, and 
when allowed to stand quietly will separate themselves into two lay- 
ers, an upper, clear, and fluid, and a lower, semisohd part. The latter 
consists of fine white and yellow flakes. True, strong drastic piu-ga- 
tives repeated several times in succession produce stools, which, as re- 



DISEASES OF THE DIGESTIVE APPARATUS. 183 

gards the color and formation of the layers, cannot be distinguished from 
those of typhus fever, but such drastic remedies are now scarcely ever 
employed even in the least rational methods of treatment. We there- 
fore have, in the formation of the layers, an important aid in the 
diagnosis of typhus fever. The absence of very profuse diarrhoea 
does not by any means prove the absence of typhus, for it is common 
to see children, after they have passed the second dentition, who, dur- 
ing the entire illness, are obstinately constipated, and in whom an 
evacuation has to be produced by clysters. The microscopic investi- 
gation of the yellowish flakes composing this lower layer reveals first 
of all: (1.) A totally formless granular mass, but little susceptible to 
reagents ; (2.) Intensely yellow-tinged scales, of pavement-epithelium 
(whole cylindrical epithelium cells are but very rarely seen) ; (3.) 
Brown, finely-granular corpuscles of various size and without mem- 
branes, as may be readily seen by cautiously compressing them ; (4.) 
Large brown, often double-contoured round or oval, and sometimes dis- 
tinctly rhomboid, refracting bodies ; (5.) Triple phosphates ; and (6.) 
Lifusoria, the constant accompaniment of every putrefaction. These 
are objects which also exist in diarrhoeic stools, and consequently are not 
pathognomonic of typhus fever. Nor is chemistry able to demonstrate 
a peculiar typhous material. Typhous stools generate more sulpho- 
hydrogen gas than diarrhoeic, a fact which may be proven by paper 
moistened in a solution of sugar of lead, and that they contain a 
greater amount of ammonia can be shown by testing them with re- 
duced litmus-paper, which they turn intensely blue. 

Nothing can be gathered, to show any difference between typhous 
and diarrhoeal stools, from the quantity of the salts, the various anal- 
yses of which I have had an opportunity of presenting more in detail 
in a former work. 

These profuse diarrhoeal evacuations generally last from eight to 
fourteen days ; then constipation sets in. Comparatively speaking, it 
is rare for diarrhoea to last longer than that period in children, as the 
intestinal complication in them is less intense than in adults. So 
long as the children are feverish, they discharge the contents of the 
bowels in bed, but it is necessary to discriminate between simply fre- 
quent involuntary discharges, the consequence of inattention, or the 
blunted state of their sensorium, and the constantly oozing away from 
them of liquid faeces, owing to the paralysis of the sphincters. The 
former condition is a common one, and denotes a very severe ty- 
phus, but its prognosis may be favorable. The latter, on the con- 
trary, is a symptom of the utmost exhaustion and profound depres- 
sion of the nervous system, and is to be regarded as an unfavorable 
sis:n. 



184 DISEASES OF CHILDREX. 

Typhous intestinal hcemorrhage and intestinal perforations are 
exceedingly rare in children ; their symptoms and consequences differ 
in no respect from those occurring in adults, and it is assumed that 
they are sufficiently familiar to the reader. 

In some malignant epidemics, a croupous process of the large 
intestines becomes associated with the disease during the third or 
fourth week, when the children will discharge dysenteric stools, sink 
rapidly into a state of collapse, and perish comatose, or during a con- 
vulsive attack. At the autopsy, an extensively-developed croupous 
membrane is found upon the mucous membrane of the large intes- 
tines, accompanied by ulcerations in various stages, such as have 
been more minutely described in dysentery. 

The spleen is generally enlarged, but its change is demonstrated 
by physical examination with much more difficulty than is usually 
supposed, this difficulty being subject to unavoidable and incalculable 
fluctuations. In a healthy child of one to two years old, a slight 
dulness over a space of barely one inch in length, and one-half an 
inch in breadth, may be detected on the left side, between the eighth 
and ninth ribs. A perpendicular line dra^vn from the middle of the 
axillary cavity to the great trochanter intersects this spot. The 
normal spleen lies with its long axis parallel to that of the body, the 
lower border projecting a little forward; but, when it becomes en- 
larged, its position becomes more and more horizontal ; still the 
lower end always remains slightly deeper than the upper. In pro- 
gressive enlargement, the lower border gTOws forward and downward, 
reaching toward the cartilaginous border of the ribs, and pushes 
itself anteriorly along the abdominal wall, while the upper posterior 
end of the spleen develops posteriorly along the course of the ninth 
rib toward the spinous processes, so that, in percussing the back 
between the spleen and spinal column, only a narrow sonorous stripe 
is now found. The larger the spleen becomes, the more does it pass 
out of the horizontal into the perpendicular position. In typhus 
fever the spleen may become enlarged to three or four fold its normal 
size, and the hypertrophy is found to be disproportionately greater in 
its longitudinal diameter than transversely. 

The splenic tumor of typhus is always easily movable, and with 
every deep inspiration is pushed downward, a fact that may be more 
easily ascertained by percussion than by pressure with the finger over 
the border of the ribs. It is particularly remarkable how difficult it 
is to feel a hj^ertrophied typhus-spleen, which often projects over the 
borders of the ribs. This is explicable by its extreme softness and 



DISEASES OF THE DIGESTIVE APPAEATUS. 135 

great mobility. The principal amount of swelling of the spleen takes 
place in the first and second week ; in the third week it begins to 
decrease, and on the fourth has become reduced to its normal size. 

The tympanitis of the alimentary canal, which is naturally some- 
times variable, according to the predominance of the catarrh and 
the retardation of the peristaltic action, is a great obstacle to the ex- 
amination of the enlarged spleen. The increased amount of space 
occupied by the intestines is not effected at the expense of the 
abdominal walls alone, but at that of the rest of the abdominal viscera 
also. The liver turns its sharp border more and more upward, and 
presses the diaphragm further up, hut the spleen is pushed u2Jward 
and backward, and invaginates itself in the distended intestines, in 
which jDosition even a very decidedly enlarged spleen cannot be de- 
tected by percussion. The diagnosis of typhus fever would therefore 
frequently be impossible, if the demonstration of the splenic tumor 
were to be regarded as essential. It does not, by any means, follow 
from this, that the percussion of the spleen is to be omitted as useless ; 
it should only be borne in mind that a greater dulness in the splenic 
region is not constant, and that consequently a well-marked typhus 
fever may exist without such dulness. 

Embolic inflammation of the spleen arises only in pyaemia, and is 
rarely seen except in children in hospital. 

The morbid alterations of the respiratory organs are just as con- 
stant as those of the digestive organs. All typhous children have 
bronchitis and cough, but those under five or six years of age regu- 
larly swallow the mucus which is loosened by cough and thrown into 
the fauces. The more intense the disease, the more insignificant and 
less frequent is the cough ; not that the bronchitis is milder, but that 
the sensibility of the mucous membrane is so blunted that the ac- 
cumulated masses of mucus no longer excite the acts of coughing. 
On auscultating the lungs, large and small sibilant rales are heard 
every^vhere. The accumulated mucus ultimately produces an occlu- 
sion of the smaller bronchi, and the well-known hypostatic spleniza- 
tion then results. These are only to be found in the posterior and 
lowest parts of the lungs, diminishing the resonance upon percussion 
in these regions. But the well-declared dulness of a pneumonic lung 
is not found in these cases, and the detecting of the finer variations 
of the percussion-sound is rendered very difficult here, by the circimi- 
stances that the splenization, in most instances, occurs in both lungs, 
and therefore a comparison of the percussion-sounds on both sides is 
impracticable. Sometimes distinct bronchial respiration is heard over 
the splenizated portions, but whether at first, or when the splenization 



186 DISEASES OF CHILDREX. 

takes place, or at the end, when, in rarer instances, it undergoes reso- 
lution, can any pathognomonic crepitation, such as is heard in pneu- 
monia, be discovered. As the splenization increases, the breathing 
becomes accelerated, the alse nasi rise with every inspiration, a symp- 
tom upon which, in the* difficulties attending the physical examination 
of the chest of restless children, too much attention cannot be be- 
stowed. Slight cyanosis at length supervenes, the cerebral symptoms 
become intensified, the frequency of the pulse augmented, and the 
children slowly succumb. Small splenizations seem to be capable of 
undergoing resolution, larger ones almost always destroy life. The 
convalescence, when splenization has taken place, is always protracted, 
and the cough does not disappear entirely till after many months. 

JLohidar pneumonia is frequently met with in the dissections of 
children who die of typhus, and may occur in the splenizated as well 
as in the sound parts. They are recognized by their firm, fixed exu- 
dation, and the granular appearance of the cut surfaces. We have no 
diagnostic signs for this condition ; for the accelerated respiration, the 
movements of the aim nasi, and the extraordinarily rapid pulse, are 
equally constant in a splenization, in a difiiised tyjDhous bronchitis 
without splenization, and in lobular pneumonia. Such circumscribed 
consolidations of the pulmonary tissues cannot be detected by aus- 
cultation and percussion. 

(Edema of the lungs is also frequently observed in the dissec- 
tions, and seems to be the efi'ects of prolonged imperfect respiration 
during the last hours of life. Pulmonary tuberculosis may develop 
itself rapidly in children who inherit such a disposition. It does not 
usually appear till after recovery from the fever, but is much rarer 
after typhus than after measles, as a result of which it manifests itself 
in a great many children. Recurrence of fever, increased cough, 
and expectoration, allow its existence to be surmised, though the 
physical examination seldom positively confirms this suspicion in 
the beginning. The bronchial glands are frequently found so much 
enlarged as to have aggravated the dyspnoea, but their hypertrophy 
cannot be diagnosticated. 

Abscesses of the larynx are said to have occurred, though I have 
not met with a simple laryngeal abscess in my dissections. In some 
there were present perichondritis and necrosis of the cartilages. 
Usually the laryngeal afi'ection first comes on in the third or fourth 
week of a severe typhus, and belongs to the secondary symptoms. 
The patients suddenly become hoarse, then completely aphonic, and 
are attacked by a barking croupous cough and fever ; the most vio- 
lent dyspnoea soon becomes superadded, and they die of frightful suf- 
focation. At the autopsy, more or less extensive necrosis of the 



DISEASES OF THE DIGESTIVE APPARATUS. 187 

laryngeal cartilages is found ; the necrosed pieces of cartilage are 
bathed in sanguinolent serum, and the glottis is oedematous. Cases of 
spontaneous recovery, with permanent hoarseness and even aphonia, 
are said to have occurred, but the most experienced physicians re- 
gard necrosis of the larynx as fatal. In adults with typhous laryngeal 
necrosis, laryngotomy is attended by tolerably favorable results. I 
have seen some individuals in whom it was performed with success, 
and would not hesitate for a moment to undertake the operation, 
should I again chance to have a child with necrosis of the larynx 
under treatment. 

Now, although, catarrhal laryngitis may also come on in typhus 
fever, as it may indeed in any other disease, and disappear sponta- 
neously, or, by the aid of counter-irritants, in a few days, still hoarse- 
ness in a typhous child must always excite the greatest anxiety, 
and it is advisable to be ready to perform tracheotomy, so that it 
may be instantly done when the dyspnoea becomes so serious as to 
endanger life. 

The skin of typhous children exhibits manifold alterations. A 
number of bright spots appear from time to time, between the fifth and 
tenth days after the invasion of the fever, upon the breast and abdo- 
men, but very seldom and sparsely on the rest of the body. These 
spots vary in size from a pin's head to that of a lentil, disappear on 
pressure, but instantly return, with uniform redness, so that it 
is impossible to decide whether the redness recurs from the centre to 
the periphery, or vice versa. JRoseola typhosa, taches lenticularis. 
Generally they are on a level with the skin, only exceptionally do 
they become elevated above it after the manner of morbilli ; they 
have no connection with the hair-follicles, and sudoriparous glands, 
and are not perceptible to the patients themselves. 

It is not always very easy to distinguish between roseola typhosa 
and flea-bites. But flea-bites are brought into the disease, fade more 
and more daily, and are not replaced by new ones, because fleas for- 
sake all febrile patients, while the exanthema of typhus fever does not 
appear for some days after the child has been seriously sick. 

The eruption of the typhous exanthema does not take place at once, 
the course is by no means typical ; some spots remain for a longer, 
others for a shorter period ; while some have already faded, others ap- 
pear again on new places, and herein we have important distinctions 
from the acute exanthemata. Typhous roseola always lasts several 
days ; when an exacerbation of the fever takes place, it becomes 
darker ; when a remission ensues, paler, and finally fades to the nor- 
mal color of the skin, having passed through a brownish or yellowish- 
red tint. Almost all seriously sick typhous children present these 



188 DISEASES OF CHILDREN. 

roseola spots ; in milder forms of typhus abdominalis they are not 
seen. The number of sjDots is of less consequence in reference to the 
prognosis than the color and duration of the eruption ; the bluer the 
spots, the more dangerous is the condition. 

The perspirations are seldom critical in typhus fever. Some chil- 
dren perspire from the very beginning, though the typhous symptoms 
are becoming more and more aggravated ; others pass into a perfect 
convalescence with a barely moist skin. 

In most typhous children Quilianes appear in great numbers. 
They have no critical and still less any unfavorable signification, and 
it is wholly inexplicable how such a dreadful fear of these harmless 
little sudamina has arisen among the laity of all classes. The 
manner of their origin is extremely simple. As a result of the ces- 
sation of the perspiration at the commencement of the fever, the 
epithelial cells lining the excretory ducts of the sudoriparous glands 
become dry, are cast off, but not washed away, forming a dam, 
which the perspiration, that has been arrested for some time, but 
which now, suddenly reestablished and profusely secreted, is unable 
to break through, thus causing an elevation of the occluded orifice, 
and the similarly desiccated layer of epidermis surrounding it, to the 
extent of a pin's head in circumference. After two, or, at the longest, 
three days, these epidermial caps burst, and the perspiration oozes 
out uninterruptedly through the once more pervious and cleansed 
passage. Microchemical investigations give evidence that the con- 
tents of the miliaries are not a serous exudation of the cutis, but pure 
sweat, and, by placing the cap of a miliary vesicle under the micro- 
scope, it ^\aQ be easy for one to convince himself that the mouth of a 
sweat-gland exists in its centre, which is recogTiized by the concen- 
tric layer of the epidermic cells, and is never seen open, but always 
closed by larger and smaller granules. 

These miliary vesicles are found largest and in greatest abundance 
upon places where cutaneous irritants, sinapisms, or ung. cinereum,* 
have been applied. There they often attain the size of a lentil ; the 
skm, after they burst, peels off in large patches, almost as in scarla- 
tina, and the new cuticle for a long time has a brighter color than that 
by which it is surrounded. This phenomenon is also easily explained, 
for, by the use of unguents, the ducts of the sweat-glands are still 
more completely closed up, and by rubefacients a congestion of the 
cutis is produced, in which naturally the glandular canals must become 
implicated. The miliaries can be regarded as critical orAj to the extent 
that they show that the long-interrupted secretion of the sweat has 
again become established, a truly desirable and encouraging symptom. 
* Oxyd of mercury ointment. — Tr. 



DISEASES OF THE DIGESTIVE APPARATUS. 189 

Furuncles^ abscesses of the cellular tissue, and heel-sores, have to- 
tally different significations. During convalescence, an extremely 
painful furunculosis, principally upon the head and nape of the neck, 
sometimes becomes superadded, causing the child much suffering for 
many vreeks, greatly retarding its complete recovery. The numerous 
subcutaneous abscesses, which appear as sequelae of the disease, pro- 
duce a like result. 

Cleanly-kept children are attacked by bed-sores at a much later 
period than adults, and the sores are less extensive. The epider- 
mis usually sloughs off from several small places on the back, over 
the sacrum, nates, or trochanters, and leaves a superficial ulcer, 
which, as a rule, heals by the application of some simple astrin- 
gent ointment. Extensive cutaneous destruction of the skin over 
the sacrum, where it becomes blue and gangrenous suddenly, and 
sloughs off in a couple of days, may occur, perhaps, in badly-ven- 
tilated hospitals ; however, I have never met with them in private 
practice. 

On the lower extremities petechim are sometimes seen in typhous 
children, who lie in very damp, miserable rooms, and are affected with 
scurvy. They differ in no respect from those observed in common 
scorbutus. 

Facial erysipelas is sometimes seen in the adult as a local mani- 
festation of a pysemic inflammation of the superior maxillary cavities, 
but I have never yet observed it in children. 

The head and nervous symptoms are not so marked in typhous 
children as would be supposed from their general irritability. Most 
of the milder cases run their course, attended only by mental apathy 
and general depression of the spirits. In severer cases, delirium of 
various degrees, at first by night, later also in the daytime, comes on, 
followed by many hours of profound coma. The di\^sion of fehris 
nervosa into a. versatilis SLiid stu2nda can be entertained no more in 
children than in adults, and only when one or the other condition has 
been continuous for several days may the therapeutic indication pos- 
sibly become changed. Sometimes the delirium lasts only one, at 
other times several days, generally, however, two to three weeks, 
when it ceases, not at once, but gradually, and leaves behind great 
irritability, and weakness of memory, which in some children may re- 
main permanent for life. Sometimes the sensorium clears up after a 
profuse epistaxis, after an intestinal ha3morrhage, or after a profuse 
diarrhoea. 

The muscular weakness of typhous children is exceedingly great ; 
most of them lie perfectly quiet upon the back, and are not even able 
to sit up. The usual tympanitis is, in part, also attributable to a 



190 DISEASES OF CHILDREN. 

paralysis of the muscular coat of the intestines ; the hardness of hear- 
ing may be explained more simply by the fact of a mechanical inter- 
ruption in the transmission of the sound, which ensues more as a result 
of catarrh of the Eustachian tubes, than by the toxic effect of typhous 
blood. The muscular weakness peculiar to typhus fever is to be dis- 
tinguished from a partial paralysis of the lower extremities, which is 
protracted disproportionately into the convalescence, but finally passes 
off spontaneously, no matter whether the much-lauded electricity has 
been resorted to or not. 

In regard to the urine of tjrphous children, and the uropoetic sys- 
tem, and genitals, but Httle can be reported, on account of the impos- 
sibility of properly collecting the urine, and the subordinate significa- 
tion of the infantile genitals in particular. I once saw diphtheritis of 
the vagina, and resulting gangrene of the labiee majora and minora 
in a girl two years old. She belonged to a wealthy family, and was 
very well nursed ; but, notwithstanding the most energetic use of 
escharotics and a general tonic and stimulating treatment, death 
ensued in a very few days. 

Metastases^ in the sense of the older school, do not occur in ty- 
phus fever. In these were included phlebitis, furunculosis, cuta- 
neous abscesses, embohc inflammations of the parenchymatous organs, 
and gangrene. But since the time that the misplacement of the co- 
agulee and the causes of the formation of emboli have, mainly 
through the labors of Virchow^ been more accurately ascertained, 
and since the time that the pysemic process and its occurrence in the 
various cavities and organs have been more thoroughly investigated, 
all those theories have completely changed. Although all the cir- 
cumstances are not yet fully explained, still this much has been eluci- 
dated : that they depend in greater part upon mechanical disturbance 
of the circulation, and hence we are not compelled to have recourse to 
the mysterious metastases. 

Actual relapses but very rarely occur in children ; though scarcely 
any typhous child progresses steadily toward a complete recovery 
without a longer or shorter interruption, because, urged by a keen 
appetite, they w411 eat indiscreetly if food is furnished them, and, 
when unable to get it, will swallow wholly undigestible substances, 
such as paper, etc. In children with an hereditary disposition, tuber- 
culosis is the most frequent sequel to which they succumb after 
many months ; in scrofulous persons, profusely-secreting exanthema- 
ta, eczema, impetigo, and mahgnant otorrhoea, ensue, along with 
which the tympanum generally becomes perforated, and the bones of 
the ear are discharged. The finale of this painful, tedious, and annoy- 
ing result is total deafness. Noma is one of the exclusive complica- 



DISEASES OF THE DIGESTIVE APPARATUS. 191 

tions of typhus ferer of cliildren ^Yllich occasionally supervenes during 
convalescence, and principally attacks tliem in badly-ventilated and 
damp localities. We have already spoken of this affection at p. 97. 

Therapeutics. — It is much easier to harm a typhous child with 
medicine than to do it good. Much injury may he done by the ad- 
ministration of emetics or drastic cathartics^ although the premoni- 
tory symptoms of typhus fever may often seem to indicate such 
medication. I frankly confess that I have occasionally been led into 
this error, and have administered to an intensely congested and con- 
stipated child, presenting a white furred tongue, an emetic consist- 
ing of ipecacuanha 3j, tart, stibiat. gr. j, and I have uniformly 
observed, as an apparent result, that the fever which followed was of 
the highest grade. That this should have been a mere coincidence, is, 
I think, altogether out of the question, and hence I deem it necessary 
to speak decidedly against the use of tartar emetic in aJl cases of chil- 
dren presenting the least symptoms of typhus fever. 

Those prophylactic measures minutely described in text-books 
(such as ventilation, proper nourishment, occupation, etc.) certainly 
deserve the utmost encouragement, but they are, in most instances, 
more easily prescribed than secured. One has quite enough to con- 
tend vdth. in having the typhous child transferred from the small back 
room, occupied by the whole family, into the so-called parlor, a com- 
paratively vacant room, containing only a few articles of luxury. In 
more commodious residences, two communicating rooms should be 
retained and appropriated to the use of the sick child, for by this 
means only can a thorough ventilation be obtained. Admitting the 
question of infection to be extremely problematical, it is nevertheless 
advisable, if only to maintain the necessary quietude, that no children, 
and, at the most, only two adult persons, be allowed in the room with 
the sick child. The temperature of the room should never rise above 
65° F., the covering should always be light, the mattresses tolerably 
hard, made of sea-weeds, straw, or horse-hair. If the typhous 
symptoms are already fully developed, it is advisable to have the 
hair cut short, by which a proper amount of cooling of the con- 
gested head is secured. Cold-water applications to it, which the 
laity generally carry out by dipping a thin piece of cotton cloth in 
cold water and spreading it out between two dry ones, and then 
tying it over the forehead, cools but for a minute at the most. 
It very soon rises to the temperature of the skin, and then it heats 
rather than cools, as one may easily convince himself by seeing and 
feeling children so treated. I do not believe that cold compresses 
laid upon the forehead give much relief, for, as they become warm 
very soon, they require to be often changed, and this act annoys the 



192 DISEASES OF CHILDREN. 

child, and thus do more harm than good. If the child be too young 
to listen to reason, or delirious in consequence of the disease, this 
manner of applying cold will not answer at all, and we will have to 
limit ourselves to douching the closely-sheared head every hour with 
cold water, holding it over a basin, while the body is protected by a 
cloth wrapped around the neck. 

The treatment of typhus fever for the first few days must be 
purely expectant, for the reason that the diagnosis cannot be 
certainly made out, and, as has already been stated, all energetic 
remedies, among which may be included leeches to the temples, for 
the purpose of combating congestion, are injurious. Hence, we 
must limit ourselves, when constipation exists, to the administration 
of some mild acidulous drinks, composed of any agreeable vege- 
table acid, or to a few drops of acid Halleri, while, if diarrhoea has 
already become superadded, the mucilaginous agents are more appro- 
priate. In this connection, I can say of calomel, that when given 
several times in medium doses, say two to four grains, it procures 
a certain but gentle evacuation of the bowels, without being followed 
by such profuse diarrhoea as tart, stibiat. or the other drastic remedies. 
An abortive effect from medication is, of course, altogether out of the 
question. Tliis expectant treatment having been pursued for from 
ten to fourteen days, and neither improvement nor aggravation of 
the disease having become manifest, a diet of more nutritious aliment 
should be commenced. 

The diet of typhous children depends upon their age and former 
manner of living. Many children, who, while in health, mainly lived 
upon milk food, will not taste bouillon and demulcent soups at all, 
which, in adults, are considered the most appropriate nutriments; 
and there is therefore no other alternative than to allow them also 
during the fever small quantities of milk, or coffee with milk, several 
times a day, although it cannot be denied that the diarrhoea is thereby 
aggravated, and that large coagulae of undigested milk may some- 
times be found in the stools. We must endeavor, by the aid of thick 
mucilaginous drinks, a thick decoction of salep-water, gum-water, rice- 
water, etc., to counteract the inevitable irritation from the lactic acid 
of the milk consumed. Children seriously ill of typhus require noth- 
ing else than cold water, and for days will refuse all other drinks, 
even milk and soups, and they do not become more emaciated than 
others who partake of nourishment several times a day. It is there- 
fore very questionable whether the food administered to typhous 
children is generally assimilated. When collapse becomes very 
threatening, or in commencing splenization, and the pulse begins to 
sink, a tonic and stimulating diet is urgently called for. 



DISEASES OF TEE DIGESTIVE APPARATUS. I93 

In coffee we have a conyenieiit and easily-procurable stimulating 
remedy, wliich, on account of its agreeable taste, is preferred to all 
other excitants, such as camphor, musk castoreum, ammoniacum, etc. 
With one cupful of strong, sweetened coffee, containing but little milk, 
the powers of the system will often revive, and the circulation receive 
new impetus. In addition, beef-broth with yolk of eggs must be 
tried, and may also be administered per anum. Camphor is very 
difficult to administer to children, and usually causes vomiting. Musk 
also behaves in the same way, besides communicating its disagree- 
able odor to the whole house. Cold affusions usually recall con- 
sciousness, invigorate the respiratory functions, and induce perspira- 
tion. If there be several unconscious discharges from the bowels 
daily, tepid baths of 98° F. should be employed, in which the children 
may be kept from five to ten minutes, or sufficiently long to thoroughly 
clean them. Miliary, roseola typhosa, and bronchitis, are not to be 
regarded as contraindicating these baths. 

Now, if by the third or fourth week a lively appetite has set in, 
the utmost precaution will have to be exercised. Mucilaginous and 
beef soups, milk, coffee, and milk-broth, may be continued till com- 
plete constipation, freedom from fever, and a clean tongue, take 
place ; then well-prepared chicken or veal may be tried. Fat nutri- 
ments and green vegetables should be avoided for a long time ; in- 
deed, it is best to defer giving them till the children are able to go 
about. 

With this simple, expectant treatment, the majority of the cases 
will terminate favorably. Should any symptoms become especially 
threatening, they will, of course, have to be specially attended to. 

The best remedy for the fever and congestion of the head is cold. 
The means by which this is accomplished are : cool temperature of 
the room, from 58 to 64° F., light coverings, hair cut short, pillow of 
horse-hair encased in soft deerskin, hourly cold douching of the head, 
cold affusions of the whole body, once or at most twice daily, and a 
bladder filled with ice to the head — this, however, is applicable only 
to large children when not delirious. I have never yet seen any bene- 
fit from sinapisms applied to the nape of the neck, the calves of the 
legs, or the feet. The redness and great 'sensitiveness of the skin, 
which last for several days, and which invariably result from those 
sinapisms, always excite sick children and make them still more 
restless. Blisters should never be applied to a typhous child. They 
heal very slowly at best, frequently become covered with a diphthe- 
ritic exudation, and even gangrenous. 

The best remedy for the excitement, sleeplessness, and delirimn, in 
this disease, is laudanum. One drop less than the number of 3'ears 
13 



194 DISEASES OF CHILDREIS'. 

of the age of the child should be given ; thus, to a child three years 
of age, two drops, to one four years, three drops, etc. ; and this may 
be repeated twice or thrice daily. I have never yet seen any of the 
bad effects attributed to opium, such as collapse, profound sopor, de- 
pression of the pulse, cyanosis, etc., from this practice, but have always 
noticed that children obtained several hours' rest, refreshing alike to 
themselves and their attendants, without any untoward change in the 
course of the fever. 

Against the great exhaustion, feeble pulse, cool, bluish skin, indi- 
cating supervening splenization of the posterior parts of the lungs, a 
tonic and stimulating treatment will have to be employed, in which I 
give to coffee the most prominent position ; wine, which, in adults, 
justly plays such an important role, must be used very carefully in 
children, because alcoholic drinks affect some infantile brains very un- 
favorably, inducing fmious delirium. Internally, it is best to give a 
few drops of valerian, camphor, or acetic ether. Nothing praise- 
worthy can be said of the tonic effects of quinine in these cases ; dry 
cups, applied several times a day to the anterior and lateral joarts of 
the thorax, are not only theoretically rational, but practically exercise 
a tolerably favorable influence upon the splenization. 

Moderate epistaxis always brings about relief and rest. The 
nurses should be instructed, to allow the blood to flow into an empty 
vessel, one that does not contain any water, because otherwise the 
amount of blood lost is usually estimated too high, and we might has- 
ten to arrest the hgemorrhage, which usually ends quite soon enough. 
The tampon is indicated, as a rule, only when the amount of blood 
lost exceeds two or three ounces. It is generally sufiicient to push 
a small piece of ice into the nasal cavity and then plug it with 
some charpie. It will scarcely ever be necessary to tampon the pos- 
terior nares by the aid of JBellocque's tube, an operation which annoys 
and frightens the child very much. To determine that the haemorrhage 
has really been checked, the child, after the tampon has been applied, 
should be laid upon the face, or the head should be held forward a 
little, as, otherwise, the bleeding may continue, and the blood may flow 
backward and be swallowed. 

Typhous diarrhoea cannot be completely arrested by any remedy ; 
opium controls it a little ; astringents and mucilaginous agents usually 
have no effect upon it. In general, however, the diarrhoeal discharges 
in children are seldom as profuse and persistent as in adults. 

Constipation is sometimes a disagreeable symptom in the course 
of tj-phus fever, occurring at certain times almost epidemically. It 
should never be relieved by purgatives, but only with clysters. If 
the latter have proved ineffectual, calomel is the only remedy which 



DISEASES OF THE DIGESTIVE APPARATUS. I95 

may be given internally, for the aqueous extract of rhubarb or castor- 
oil is difficult to administer to children. In conclusion, I feel it a 
duty to admonish against the use of all debilitating measures, to spare 
the strength of the child as much as possible under all circumstances, 
and to carefully avoid the practice of active antiphlogistic measures. 

B. Cholera Asiatica. — The history, epidemic character, manner 
of propagation, and etiology of epidemic cholera, have of late been so 
thoroughly investigated, that we may very properly omit them alto- 
gether here, especially since cholera Asiatica in children has mani- 
fested no peculiarities. But the symptoms which attend it in children 
differ materially from those manifested in the adult, and it is this dif- 
ference only which we will here consider. 

Since diarrhoea in general is extraordinarily frequent in small chil- 
dren, and is constantly reproduced by the irritation of improper food 
or dentition, it is therefore still more difficult to decide in them than 
in adults whether a diarrhoea originating during the prevalence of an 
epidemic of cholera is to be attributed to cholera-poison or to the 
above-mentioned ordinary causations. It is certain that, during an epi- 
demic, all children, even nurslings, are more predisposed to diarrhoea, 
and that it is more difficult to arrest it, than during periods free from 
epidemic influence. Diarrhoea thus induced may either continue as 
such for a long time, and be arrested after many weeks, without any 
additional serious symptoms having become superadded, or it may 
pass into real cholera. In many cases, however, no diarrhoea at all 
precedes, and very healthy children are suddenly attacked by profuse 
purging and vomiting, and in a few hours display the most perfectly- 
developed cholera, with profuse bright-yellow discharges, cramps, dis- 
appearance of the pulse, algor, cyanosis, and suppression of urine. 
The discharges are seldomer of the rice-water character than in adults. 

Two stages may also be distinguished in children : (1.) The stage 
of the attack, and, (2.) The stage of reaction. Few children, how- 
ever, reach this stage, most of them perishing during the attack. The 
secondary processes and the exhausted condition belong to the phe- 
nomena of reaction. In general, however, three principal classes of 
phenomena may be distinguished in cholera : (1.) Those belonging to 
the intestines ; (2.) Those of the circulation and respiration ; and (3.) 
Those of the kidneys. 

(1.) By far the most important are the derangements of the intes- 
tinal mucous membrane ; they are invariably the first to appear, and 
probably are the causation of the alterations of the circulation, and 
very certainly of those of the kidneys. 

It is a remarkable circumstance that the stools of children seldom 
become as white as those of the adult, but almost alwavs retain a 



196 DISEASES OF CHILDREN. 

yellowish tint ; in other respects, they present neither chemical nor 
microscopical modifications worthy of note. They are rarely very 
copious, but five to six thin evacuations in an infant suffice to induce 
the most dangerous collapse. In previously marasmic children, col- 
lapse may supervene even after the first thin passage, followed by a 
few convulsions, and in a few hours by death. When the stools be- 
come pink red, a coloring due to a small admixture of blood, the prog- 
nosis may be set down as absolutely hopeless. 

No child under one year of age is able to resist a profuse cholera 
purge longer than forty-eight or at the utmost sixty hours, death tak- 
ing place in consequence of the enormous loss of the fluids of the 
body. But when the discharges are seen to grow less and more in- 
frequent, then more yellowish, more sohd, and assume an intense but 
not an actually fetid odor, a favorable prognosis may be given. 

As respects the vomiting in the cholera of children, there is a 
marked difference from the adult. In the latter, it is observed in 
nine-tenths of the cases, in the majority of cholera children not at all, 
or at the most once or tmce, and the profuse vomiting of every 
thing shortly after it has been introduced into the stomach scarcely 
ever occurs in such children, a fact that is the more remarkable, 
as children in health vomit oftener and easier than adults. The 
act of vomiting is accomplished by a very slight exertion only : the 
food last taken is first thrown up, and soon followed by the real tran- 
sudation from the gastric mucous membrane, generally mixed with 
the drinks, which, on account of the tormenting thirst, are constantly 
swallowed in large quantities. In regard to the chemical properties 
of the matter vomited by cholera children, but little, so far as I am 
aware, is known, because it is always ejected on to the garments or 
bed, and cannot therefore be obtained in sufficient quantity for projDer 
chemical examination. 

The absorbing function of the gastric and intestinal mucous mem- 
brane is very much diminished during the attack, and for that reason 
large quantities of toxic substances, such as morphine, strychnine, 
belladonna, etc., may be administered without producing their normal 
effect ; sometimes, however, when the transudation already happens to 
be undergoing spontaneous diminution, dangerous absorption sud- 
denly takes place, and attention on this account is here called to that 
point. As this class of remedies is repeatedly selected for new thera- 
peutic experiments, it is well for the experimenter to know that, 
deceived by the first dose, appearing to be inert, he may suddenly 
find it to have produced a poisoning, and to have destroyed the last 
hope of the recovering child. 

Soon after the commencement of cholera, the abdomen quickly col- 



DISEASES OF THE DIGESTIVE APPARATUS. IQY 

lapses, and becomes so soft and flabby tbat the intestinal coils may 
be recognized. Percussion shows that the stomach contains a toler- 
ably large quantity of gas, while the whole intestinal tube is filled 
with transudation, and therefore a perfectly dull sound is produced. 
The patients seem to suffer less from true colic than from a feeling of 
incessant nausea, which they manifest by frequently opening the 
■ mouth, protruding the tongue in a peculiar manner, and an anxious 
expression of the countenance. 

It is a remarkable fact, that the most profuse diarrhoeas of cholera 
Asiatica do not redden the anus, while, on the contrary, in enteritis 
foUiculosa,. or the effects of thrush, it becomes red and eroded after a 
few evacuations. 

The next effect of this transudation, and the complete abolition of 
the function of absorption, is, naturally, a marked diminution of the 
whole volume of the blood, and a disappearance of the fluids from the 
parenchymatous organs and serous sacs. Whether all subsequent symp- 
toms are induced by this diminution of the blood and fluids, or whether 
the poison of cholera produces a specific action, in some other place 
besides the intestinal canal, are still undecided questions. The course 
is so extremely rapid in children, that a direct action of the cholera- 
poison upon the heart and pulse seems probable, as sometimes the 
pulse and the diastolic sound of the heart disappear almost with the 
first liquid passage. 

(2.) During the first few hours of the cholera attack, the circula- 
tio'ri is said to be increased in activity, accompanied by violent palpita- 
tion of the heart, and intense beating of the arteries ; usually, however, 
the impulse of the heart, and of the radial pulse, become weaker 
hourly from the very commencement, and the latter soon disappears 
altogether, while the cardiac sound continues to grow weaker and 
duller, till the diastole alone is heard over the large vessels, even after 
it is imperceptible over the apex itself. 

The pulse, in children under one year old, retains its normal fre- 
cjuency; generally it is about 100 in the minute; soon, however, it be- 
comes thready, and then disappears altogether. The observations 
which J. 3feyer made in the adult — to the effect that the jDulse, in cases 
of spontaneous reaction, remains absent for a long time, but after it has 
once returned does not readily disappear again ; and that, on the other 
hand, in cases where reaction was induced artificially by stimulants, 
the pulse acts reversedly — are equally true of cholera of children. Very 
frequently it is possible, by a high temperature, a mustard-bath, or a 
camphor-powder, to restore the pulse, it is, however, very seldom pos- 
sible to preserve it ; it soon disappears again, never to return. On 
the whole, it may be observed that pulseless children, when this state 



198 DISEASES OF CHILDREN. 

has existed for several hours, are generally lost, while there are many 
instances recorded of adults who have been pulseless for from twelve 
to twenty-four hours, and even longer, and have nevertheless recovered. 
In cholera typhoid, various anomalies of the pulse, such as intermit- 
tent and extremely-rapid pulses, occur ; a very slow pulse, even forty 
to fifty in the minute, the like of which is only met vrith in hydro- 
cephalic children, is not a symptom inconsistent with a favorable 
prognosis. 

The veins are turgid with semi-fluid, grumous blood, on account of 
the tardy venous circulation, resulting in part from enfeebled vis a 
tergo, and in part also from the suction-power of the right side of the 
heart having become enfeebled. This stasis of the capillaries is seen 
in the lips, fingers, and eyelids, as cyanosis. In cholera, well-nourished 
children only become cyanotic, while emaciated and marasmatic chil- 
dren acquire only a correspondingly yeUomsh-gray discoloration. 

The respiration during such sudden and profound disturbances of 
the circulation very naturally becomes affected. By phj'sical examina- 
tion, nothing abnormal can be detected in the lungs, but, in the per- 
formance of the respiratory act, changes are soon observed. The child 
breathes irregularly, frequently sighs deeply, and suffers intense dysp- 
noea. But the most remarkable phenomenon of all, is the coolness of 
the breath, which may be distinctly perceived by holding the hand, es- 
pecially its dorsal surface, over the mouth. Prognostically this cool- 
Qess of the breath is of the greatest importance, and is palpably the 
most distinctive sign of the arrest of the metamorphosis of the tissues. 
With this, the coolness of the extremities always stands in direct re- 
lation. Palpation of the nose, forehead, hands and feet, as well as 
the temperature of the expired breath, with a warm hand, will be suf- 
ficient to enable the experienced physician to form an opinion as to 
the severity of the disease, and its probable termination. 

(3.) The morbid changes of the kidneys are as constant in children 
as in adults. The autopsy discloses the signs of stasis and • acute 
Bright's disease. It is, however, impossible in most cases to discover 
these facts by an examination of the urine during life, because the 
patients either do not pass any urine at all, or it dribbles away from 
them into the diaper, and cannot be obtained for examina'tion. When 
children recover from a severe attack of cholera, as they occasionally 
do, albuminuria and casts will be found. How long the secretion of 
urine may be arrested, and yet recovery follow, it is difficult to say, 
for the diapers are incessantly wetted with the profuse stools, so that 
an admixture of urine cannot easily be recognized. 

In consequence of the arrest of the secretion of urine, a violent 
revolution in the entire metamorphosis of the tissues very naturally 



DISEASES OF THE DIGESTIVE APPARATUS. 199 

ensues, and the retention of the urates must be regarded as the main 
effect of this condition. The tonic and clonic spasms, at least of the 
face, bj which all cholera children are attacked, are most probably at- 
tributable to it, while the great exhaustion, the rapid collapse, and the 
aphonia, are due more to the speedy loss of the serum than to any 
other cause. 

When children recover from an attack of cholera, the first urine 
passed contains albumen, and is rendered opaque by the urates ; a 
cholera tj-phoid then develops itself, in which the skin becomes hot and 
dry, the pulse hard and extremely frequent, the tongue inclined to dry- 
ness, and the symptoms of cerebral congestion come on. In many 
cases, however, death is caused by convulsions, while in others marasmus 
develops itself, from which but few children escape with their lives. 

If we subject the symptoms of cholera in children to a resu7ne, we 
find the follo^^dng variations from those of the adult : 

(1.) The stools remain yellow for a long time. (2.) Collapse comes 
on very rapidly in feeble, atrophic children, and death ensues before 
many colliquative stools have passed. (3.) Vomiting is rare, and in 
many instances absent altogether. (4.) The comparative mortality is 
much greater; at least eighty per cent., of the children who become 
cool and pulseless, perish. 

The pathological anatomy, which in cholera is generally very 
meagTe, exhibits nothing peculiar in children. In those who suc- 
cumbed early in the attack, the following conditions are found, viz. : 
a peculiar tenacity of the serous membranes, dryness of all the pa- 
renchymatous organs, cyanosis of the skin, black masses of grumous 
blood in the veins and heart, the small intestines filled with a whitish 
fluid, their mucous membranes a rosy tint and completely denuded of 
epithehum, the kidneys infiltrated, the urinary tubules revealing ex- 
tensive desquamative catarrh, and the bladder empty. 

If, on the contrary, they died from cholera typhoid, the cyanosis of 
the skin is less marked, the serous membranes are still glutinous, the 
brain is oedematous, lobular infarctions are frequently found in the 
lungs, the small intestines contain a thick, tenacious, greenish mucus, 
their mucous membranes are less infiltrated and injected, and the soli- 
tary glands of the large intestines are swollen or ulcerated. The 
bladder now contains a little opaque urine, in which generally albu- 
men may be detected. 

Treatment. — The therapeutics of cholera in children, as may be in- 
ferred from the relative mortahty, is extremely unsatisfactory^ though 
the most important part of the treatment, the artificial maintenance of 



200 DISEASES OF CHILDREN. 

the temperature, is more easily effected than in adults. The gen- 
eral discussion of its prophylaxis may be properly omitted here, as 
this has lately been very minutely described in various text-books, for 
example, in Griesinger's Infecting Diseases. The treatment of cholera 
diarrhoea, and of cholera in children, differs but little from that practised 
in the adult. The attempts to check the purging in any manner, as 
soon as the stools have become watery, bright yellow, or, still worse, 
rice-water-like, prove totally fruitless. For simple diarrhoea of teeth- 
ing, which, during the prevalence of an epidemic of cholera, must al- 
ways excite the greatest anxiety, laudanum will always prove the 
most reliable remedy ; but, if true cholera come on, no benefit what 
ever, according to my experience, need be expected from it. The tinc- 
ture of opium may be given in from four to five times the usual doses. 
Should the diarrhoea, however, continue unchanged, as it often does, 
or if it have existed for one or two days before the narcotic was 
administered, it may suddenly be arrested, and be followed by the 
most violent signs of narcotism. Astringents, and especially all 
those remedies to which any constipating effect has been ascribed, 
are useless. 

It should be borne in mind that, in consequence of the profuse 
exosmotic current, which takes place toward the mucous membrane 
of the stomach and intestinal canal, no absorption whatever probably 
occurs. In the next epidemic, therefore, I intend to select some other 
places, which seem to be more disposed to absorption, for example, 
the bladder, urethra, and vagina, and try different remedies, espe- 
cially of the class of narcotics. Injections into the veins are very 
difficult to perform, owing to the smallness of the vessels in children, 
and this practice will hardly ever be successful, on account of the dan- 
ger of admitting air into them. 

As regards the diet and regimen, it should be clearly stated that 
the proscribing of drinks, by which it is intended to check the pro- 
fuse diarrhoea, is totally useless and cruel. Children certainly ought 
not to be allowed too much at one time, but they may drink as 
often as they feel thirsty. Large quantities of fluids, when swal- 
lowed rapidly, are liable usually to cause vomiting. Children prefer 
cold water to every thing else, and the nursling will draw actively 
at the mother's breast as long as its strength will allow ; and, when 
it has become too feeble, mil swallow the milk taken from the breast 
of the mother with avidity. An administration of other nutriment, 
except plain demulcents or lukewarm milk, is, of course, altogether 
out of the question; warm chamomile and peppermint teas are re-* 
jected by most. 

The principal indication is, manifestly, an artificial continuous 



DISEASES OF THE DIGESTIVE APPARATUS. 201 

warming of the chilled surface of the body, which is best accom- 
plished by placing the child in a hot-water bath of 30° R. (100° F.), 
in which one or two ounces of ground mustard are suspended. The 
skin thus reddened should be dried quickly, the child then put to 
bed, and surrounded by bottles filled with hot water, and the diapers 
should not be changed oftener than once in two hours. By keeping 
up a high temperature, the pulse that has totally disappeared some- 
times becomes again perceptible, the diarrhoea diminishes, the tip of 
the nose, the ears, and the breath, become warm, and a reaction sets 
in, which, even then, very frequently indeed, terminates in a fatal 
typhoid condition. 

The most important indication in the typhoid condition is the fre- 
quent administration of drinks, in order to restore the occluded pas- 
sages in the kidneys, and render them again permeable. The nervines, 
such as camphor, musk, coffee, etc., and the so-highly-lauded quinine, 
seem to me to have no favorable effect upon the course of this disease. 
During convalescence, the utmost caution will have to be exercised so 
long as any abnormal changes whatever can be detected in the stools. 
Children at the breast should retain their wet-nurses from six to eight 
weeks after the attack of cholera, and should be weaned very grad- 
ually ; those brought up by hand should be fed upon mucilaginous 
soups for a long time, and slowly habituated to a milk-diet. 

Consohng and important as the prompt and efficient services of 
the physician may be regarded, it is problematical whether all his 
therapeutic measures 'are of the shghtest use to the child with 
cholera. 

(16.) Entozo^, Enthelminthes, Helmi]sthiasis (Woem-Dis- 
ease). — Before we enter upon the discussion of the effect of the single 
helminthia, it seems proper to give the subject a simple zootomic con- 
sideration, for which purpose we take, as a part of our ground-work, 
Bamberger'^s excellent monograph upon entozo^e, found in his treatise 
on the diseases of the abdomen. In the alimentary canal of children 
there are found : (1.) Taenia solium ; (2.) Bothriocephalus latus ; (3.) 
Ascaris lumbricoides ; (4.) Oxyuris vermicularis ; and, (5.) perhaps, 
also Tricocephalus dispar. Trichinae, which of late have attracted 
so much attention, may occur in older children as vfell as in adults. 
Small children, so far as I am aware, enjoy a total exemption from 
the trichina spiralis. This is readily accounted for by the fact that 
they do not eat the meat of the hog, which is knovm to be a fruit- 
ful source of supply of this entozoon. Since trichinosis of children 
differs in no respect from that of the adult, a description of it may, 
therefore, be omitted, as the numerous monographs upon this subject 



202 DISEASES OF CHILDEEN. 

liave obtained the most extensive circulation and study, and are acces- 
sible to everj reader. 

(1.) T^eni^ solium, and (2.) Bothrioceplialus latus. (Cestodi^.) 
Tctinia solium (T. cucurbitina, armata, cbain-worm), PI. IV., Figs. 
4-7, is a jellowish white, tape-like, jointed worm, fifteen to thirty 
feet in length, and three to five lines in breadth. Like all Taenia, it 
has the male and female sexual organs united in each of its developed 
joints, and propagates itself by eggs, which, however, never attain 
to maturity in the alimentary canal itself. The head, to the naked 
eye, appears as a white point, on which, with a No. 4 magnifying 
glass, blackish pigmented suckers may sometimes be detected. Be- 
tween these is the conical proboscis surrounded by a double circle of 
hooks, but the individual hooks are so small, that a magnifying power 
of two hundred is required to see them distinctly. The neck is sev- 
eral inches in length, not jointed, resembles a flattened thread, and 
gradually merges into the body, which, as already stated, is jointed. 
The first joints have a greater transverse diameter, which becomes 
gradually less posteriorly, till toward the end they are square or 
parallelogram in shape, with blunt corners. On the latter the genitals 
are distinctly seen, for a projection is found on their borders with the 
orifices for the vagina and penis, and the ovary is seen through their 
translucent walls. This projection is generally situated alternate- on 
the borders of the joints. 

New joints constantly form at the head, while at the tail the old 
joints are constantly cast off. These cast-off segments or joints 
appear in the stools, and are frequently compared to pumpkin-seeds 
in appearance, and thus the definition of taenia cucurbitina has 
originated. 

(2.) Bothriocephalus latus (PI. lY., Figs. 1-3, tsenia lata, the broad 
tape-worm) is very similar to the preceding, but is distinguished 
from it by the following peculiarities : It is of a darker grayish 
color, the head oblong, with longitudinal depressions, without snout 
and without the rows of hooks. The neck is much shorter ; aU the 
joints are broader than they are long, and overlap each other in the 
form of slates upon a roof; and the most characteristic feature observ- 
able on every joint is, that the sexual orifices are not on the border, 
but in the centre o/*the joints. 

The eggs are of a brownish color, and glisten through the central 
portion of the translucent walls of every joint like yellowish-brown 
rosettes. The bothriocephalus has, in addition, the peculiarity of not 
readily casting off single mature joints, but always whole rows of 



DISEASES OF THE DIGESTIVE APPARATUS. 203 

joints, and this materially aids us in forming the diagnosis, since we 
have to rely upon the history of the patient almost entirely. 

These two kinds of worms display a remarkably reciprocal exclu- 
sion. Thus the bothriocephalus occurs only in Russia, Poland, and 
Eastern Prussia, as far as the Weichsel, while taenia solium is seen in 
all the rest of the countries of Europe, except Switzerland, where, 
according to Mayer- Ahrens, they are both observed. 

They are extremely rarely found in children under one year of 
age, in nurslings probably never. Taenia solium, according to KiXch- 
enmeister'^s investigations, originates from cysticercus cellulosa of 
the pig, and therefore occurs only in children who partake of hog's 
meat. 

(3.) Ascaris lumbricoides (Class of Nematodise), round-worm. 

The round-worm, PI. IV., Figs. 8 and 9, is a round, yellowish, or 
reddish worm resembling the earth-worm, of five to ten inches in 
length, and one to three lines in thickness. It is very slightly flat- 
tened, has a mouth and an alimentary canal ; the head is distinguished 
from the body by a constricted point, and is composed of three 
papillae, which, during the act of sucking, are capable of dilating 
themselves into a broad suction-cup. The male and female can be 
easily distinguished ; the male is smaller than the female, and has a 
curved tail, and occasionally a couple of very fine small white hairs 
are seen close to the end of the tail, indicating the position of the 
penis. According to JTuchenTneister, if the body of the female be 
pressed, a thin bag (the ovaries) is squeezed out from the vaginal 
opening, which is located in the anterior half of the animal, attended 
by an efiusion of a milk-like substance (the eggs). If the male worm 
be squeezed, a milky juice (semen) flows out from near the anus, 
without any rupture or prolapsus taking place. The skin, according 
to CzermaJCy consists of six layers, and is formed of tape-like trans- 
verse rings which are not endless, but sometimes split dichotomously, 
and usually terminates at the lateral lines of the animal. 

The round-worm inhabits, by preference, the small intestines ; is 
seldom found solitary, but in numbers of from five to ten, and some- 
times as many as two or three hundred. It is much more frequently 
met Avith in the alimentary canal of children than in that of adults. It 
does not occur in nurslings, but may in small children who are brought 
up by hand on meal-jam or toast-broth. The eggs of this worm are 
undoubtedly introduced into the alimentary canal with the food ; at 
least no other supposition can be assumed, since, according to TT Sie- 
bold, the female ascarides never bring forth any li\dng young, nor is 
the spawn ever found in the human intestines. They seem to prefer 



204 DISEASES OF CHILDREN. 

amylaceous nutriments, but it does not follow from this fact that all 
children who readily eat bread harbor ascarides. Were it otherwise, 
there would certainly be no child that did not suffer from them. 

(4.) Oxyuris vermicularis (Ascaris vermicularis, spring-worm, in- 
testinal moth, maggot-worm). Class of Nematodise, PI. lY. Figs. 10-13. 

The name oxyuris is only applicable to the female, not to the male 
worm. The female is thin, yellowish white, of from two to five lines in 
length, with a straight, awl-like, pointed tail. The male is barely a line 
in length, arid has a strongly-curved tail. Both have a bulbous head, 
with two lateral, bladder-like membranes. The female is found in 
vastly greater numbers than the male, and the latter is never found in 
the stools^ because it adheres very firmly to the intestinal mucous mem- 
brane, from which, according to Zenker, it may very readily be scraped 
off with the mucus after death. The male worm is still more easily 
collected when the alvine secretions of the large intestines have been 
washed away by diarrhoea. The usual abode of the oxyuris is in the 
rectum. In the large intestines it is found in small numbers only, 
and scarcely, if ever, in the small intestines. It travels from the rec- 
tum, especially when the children lie in warm beds, and wanders to 
the vagina in girls. Kuchemneister says it is a " superstition " to re- 
gard them as only or chiefly peculiar to childhood, and affirms that he 
has observed them twice in the adult. But every experienced physi- 
cian, who practises in a region where oxyuris is at all common, will be 
able to offset those two adult cases by as many hundreds of cases of 
children, and hence I see no good reason at all for rejecting this 
" superstition." 

(5.) Trichocephalus dispar (Nematodise). Whip-worm. PI. IV., 
Figs. 14 and 15. 

The trichocephalus is a white, long worm, of from one to two inches 
in length, as thin as a hair at the head, and very gradually grows thicker 
posteriorly, presenting a strong resemblance to a whip-stalk. At the 
tip of the thin extremity an unarmed mouth is found, in w^hich the 
oesophagus terminates. In the female the posterior part is straight, 
and exhibits a simple, straight vagina, but in the male it is spirally 
twisted ; the end is provided with a small prepuce and a penis. 

This worm is found almost exclusively in the caecum and ascending 
colon, and is very seldom seen in the faeces, because, as it seems, it 
very unwillingly leaves the gut. Once, while making a post-morte'in 
examination of the body of a girl fifteen years old, who died of chol- 
era on the fourth day, after the most profuse diarrhoea, I found at 
least thirty of these animals in the ccecum, and all the physicians 



DISEASES OF THE DIGESTIVE APPARATUS. 205 

present at the examination expressed their surprise at the animals 
having remained in the bowels for four days with such liquid and 
profuse evacuations. It is very rarely met with in children, and in 
fact has only been described for the sake of completeness. 

Symptoms. — In regard to the symptoms which are occasioned by 
the entozofe, much has already been written and disputed. Our pred- 
ecessors undoubtedly attributed too great an importance to intestinal 
worms, and believed that many serious diseases were caused by them, 
for no other reason than that, during such disease, these worms passed 
off and then restoration to health followed. The symjDtoms attributed 
to them became more and more numerous and variable, and finally so 
confused and improbable, that intelligent physicians began to deny the 
existence of worm-symptoms, as many do even at the present day, 
especially the Viennese physicians. Like every thing else that is 
new, this negation found many adherents, and for some time it was 
very fashionable for one not to know any thing about the anthelmin- 
thias. Some symptoms, however, cannot be ignored, and, in order to 
proceed safely, I will only mention those which I myself have observed 
many times. They may be divided into local, general, and reflex 
symptoms ; the imaginary symptoms which in adult tape-worm pa- 
tients occur so frequently, we may in the Peediatria, fortunately, ignore 
altogether. 

A. Local S>yinptom8. — Of the local symptoms, those which arise 
from the direct irritation of the entozo83 are first of all to be mentioned. 
Pain is a very frequent symptom ; sometimes it is pinching, gnaw- 
ing, boring, etc., and is uniformly intermittent. Various articles of 
food, especially those which are very salty, or aromatic, or sour, 
increase it, and consequently all kinds of fruit aggravate it, while 
milk, oleaginous and fatty nutriments, generally mitigate it. The 
appetite in worm-patients is usually normal, sometimes, however, 
diminished ; it is not easy to decide in children whether it is in- 
creased by worms, because it is well known that at different times 
an abnormal augmentation of the appetite occurs in every child. 
Generally the cause of an augmentation of the appetite is to be sought 
in a more rapid development or more active exercise, and bodily ex- 
ertion, and not in the existence of worms. Vomiting may become 
superadded, either as the effect of the entrance of a worm into the 
stomach, or as a reflex phenomenon, having its source in the irritated 
mucous membrane. Ascaris lumbricoides frec[uently find their way 
into the stomach, where by their movements they seem to induce retch- 
ing and vomiting, by which, to the great horror of the parents, they 
are sometimes thrown up. The youngest child that I saw throw up 
a round-worm was nine months old, and had merely partaken of a little 



206 DISEASES OF CHILDREN. 

meal-broth, along with the milk of the mother, for only three months. 
The stools are generally irregular ; sometimes there is constipation, 
and sometimes diarrhoea is present ; with the latter, as a rule, a great 
number of the entozoee are expelled. The large masses of mucus (so- 
called worm-nests), which occasionally pass off from tape-worm pa- 
tients, are seldom observed in children, because tape-worm is rare in 
children. 

In gMs, oxyuris sometimes travel from the rectum, where they 
occasion incessant itching, into the vagina, redden its mucous mem- 
brane, and give rise to leucorrhoea. The incessant tickling sensation 
they produce is often the stepping-stone to onanism, of which practice 
it is seldom possible to break them, even though the oxyuris have 
long been expelled. In boys they sometimes crawl up under the pre- 
puce, from which balanitis, erections, and similar inclinations to onan- 
ism, may likewise be developed. 

The round-worms extend their wanderings even farther than the 
oxyuris. They sometimes get into the oesophagus, causing vomiting, 
thence into the mouth and nose, and are even said to have passed 
into the larynx and produced suffocative attacks. In some post-raor- 
tem examinations, abscesses of the liver have also been found, in 
which one or two round-worms were hidden. These have doubtless 
found their way into the gall-ducts through the ductus choledochus, and 
then caused inflammation, hepatic abscesses, and death ; they have 
been also found in the ductus pancreaticus and appendix vermiformis, 
where they produced irritation and suppuration. The extremel}^ rare 
instances in which encysted ascarides were found in the peritoneal sac 
have lately been doubted altogether, because no organ can be de- 
tected on any part of the body of the worm by which it would be able 
to perforate the intestines. I have not seen such a case, and am there- 
fore unable to decide ; but Y. Siehold^ one of the most eminent hel- 
minthologists, and known for his conscientious observations, maintains 
that the ascarides are able to insinuate themselves, with their firmer 
cephalic extremity, through the coats of the intestines, and penetrate 
into the abdominal cavity, without it subsequently being possible to 
detect any trace of the perforation of the bowel. The penetration of 
the muscular coat is indeed possible, but how the compact mucous 
membrane and the dense serous coats are made to give way before so 
mild a pressure as the round-worm is capable of exercising, is really dif- 
ficult to imagine. 

B. General and Reflex Phenomena. — Itching of the nose is a 
very common symptom of the jDresence of worms ; still, it should not 



DISEASES OF THE DIGESTIVE APPARATUS. 207 

be forgotten that almost all children bore and rub their nostrils and 
nose, whether they have worms or not, so that this symptom has no 
great value. I have often seen dilatation of the pupils disappear with 
the expulsion of ascarides, and I consider it, though not a very con- 
stant symptom, one sufficient to merit regard. ComTilsions of va- 
rious kinds, especially epilepsy and chorea, have been looked upon as 
being connected with entozose. As these views are also entertained 
by the laity, I have in many instances been requested to treat such 
children for worms, but have been unable to detect any entozose, or 
any change in the convulsions, notwithstanding the employment of the 
most energetic remedies. The occurrence of worms in choreic and 
epileptic patients seems, therefore, to be a mere coincidence. 

I doubted, until I finally convinced myself of it, whether worms can 
produce severe hydrocephalic symptoms. Some years ago a child was 
brought to our children's hospital in a dying condition, having been first 
attacked by convulsion a few days before. It presented all the signs 
of a child dying from acute hydrocephalus, and died in a few hours. 

To our great surprise, at the autopsy we found the brain and its 
meninges, the heart and lungs, the liver, spleen, and kidneys, in a per- 
fectly normal state, but in the intestinal canal there were more than a 
hundred round-worms, rolled up in small and large balls, at some points 
completely choking up the calibre of the canal ; the mucous membrane 
itself in the same regions had become reddened.* 

Biagnosis. — By these local and general symptoms a probable di- 
agnosis may, it is true, be arrived at ; a certain one, however, is only 
derived from the appearance of helminthisg in the evacuations, or, in 
the case of tape-worm, the appearance of single pieces. Since the or- 
dinary vermifuge remedies are harmless when given to children free 
from intestinal catarrh or other disease, we are justified in adminis- 
tering them to children presenting the symptoms just described, in 
the hope that the expulsion of worms may confirm the diagnosis. 

Treatment. — (1.) The expulsion of tape-worm may be undertaken 
in children of one year and over, providing they are free from diar- 

* That the reflex symptoms are sometimes of the most peculiar and variable kind 
is seen from the two following singular eases, which lately occurred to me. In the 
first, a girl three and a half years old, they manifested themselves by a croupous cough, 
differing in no respect from that occurring in genuine croup ; in the second, a boy 
five years old, by severe and protracted toothache of almost all the teeth of the up- 
per jaw, though, on examination, they were all found to be perfectly sound. In the 
former, the cough had a periodic character, i. e., it would come on whenever the oxy- 
uris accumulated in any considerable numbers in the rectum, and would disappear as 
soon as these were expelled ; in the latter, the toothache persisted until a long round- 
worm was expelled, since which the boy has been free from it. — Tr. 



208 DISEASES OF CHILDREN. 

rlioea, and otherwise liealtlij. Very young or teething children toler- 
ate badly even the mildest tape-worm remedies. The simplest and 
surest remedy is cortex radic. punicm granati. The precaution, how- 
ever, should be taken to have it fresh and sufficiently macerated. For 
children of from two to five years, the following formula will be found 
useful : ]^ . cort. rad. punic. granat. rec. | j, macera c. aqua fontan. 
libr. j, per horas 24 dein coq. per hor. 12 ad remanent. ^ vj. Two ounces 
to be given at half-hour intervals in the morning, fasting, the bow- 
els having been gently moved the preceding day by the use of boiled 
dry prunes. It is advisable to have a double quantity of the gTanat- 
bark decoction prepared, because occasionally one or the other por- 
tion is thrown up, and in that case should be repeated in half an hour. 
After one or two hours, the whole worm is usually expelled. If this do 
not take place, or if the head of the tape- worm cannot be found in the 
stools, the same procedure may be repeated after a few days, without 
any detriment to the health. Generally no persistent diarrhoea nor 
colics are produced by this remedy, but, when they do occur, they may 
soon be relieved by emulsions. 

Where the fresh bark of granat-root is not obtainable, or if the 
child cannot be induced to take it, other remedies may be resorted 
to. Among these we may mention : Ext. felic. mar. cether 3 ss, the 
blossoms of Brayera anthelminthica, of which an ounce may be given, 
mixed mth honey into a confection. Drastic purgatives, such as 
gummi gutt% colocynth^ and croton-oil, should under no circumstances 
be given. In sickly children this treatment for tape-worm should 
never be practised. I am conversant with cases in which, notwith- 
standing the presence of the tape-worm, children have gradually 
recovered their health, the worm not seriously influencing develop- 
ment. 

(2.) Ascaris lumbricoides seldom produce any serious disturbance 
or characteristic symptoms, and often pass off in large quantities from 
perfectly healthy children, in which neither any subjective nor objec- 
tive symptoms preceded. The usual method of expelling them con- 
sists in active purgation with the following substances, viz. \pulv. seniin. 
cincB 3 j, 2iXidi2yidv. rad. jalap. 3 ss, divided into four or five jDowders^ 
which are to be taken at intervals of two hours. It is easier, as a rule, 
to administer these powders mixed with a little water, than when 
made into a confection with honey. Owing to the alkaloids having 
come into such general use of late, it is customary to employ the es- 
sential principles of remedies instead of the gross substance, as they 
possess all the virtues in much smaller bulk. Hence a few grains of 
santonine are now given in place of a drachm of cinse-seed. But the 
effect of santonine is by no means as brilliant as has been claimed by 



DISEASES OF THE DIGESTIVE APPARATUS. 209 

some ; on tlie contrary, it is very problematical and much inferior to 
tlie ordinary cin^e-powder. Although the fear of calomel, with which 
some individual therapeutists are affected, is by no means well ground- 
ed, its employment as an anthelmintic has no defence. Children are 
hable to crush the wafer in which the powder is enveloped, in the 
mouth, and then generally get stomacace from it. In all the text- 
books on the diseases of children, ol. ricini plays a manifold part, and 
some physicians omit no opportunity to make the children happy by 
prescribing a few teaspoonfuls of castor-oil. I have frequently tried 
to administer it, but have succeeded in but few cases, as most children 
refuse to swallow it and spit it out. I have therefore discarded it al- 
together. 

(3.) Against oxyuris vermicular is internal remedies are of but 
little use ; on the other hand, it is very easy to remove them by clys- 
ters, since they are almost wholly located in the rectum. Various 
vermifuge remedies, such as decoctions of garlic^ onions^ asafoetida^ 
Valeriana, tanacetum, or a few drops of turpentine, camphor, salt 
water, and even a weak solution of corrosive sublimate, may be added 
to the clysters. The principal object, however, is always to soften the 
contents of the rectum, and to cause their expulsion once a day. This 
is easily accompHshed with simple cold-water. Two cold-water clys- 
ters daily, continued for four weeks, will invariably expel all oxyures. 
If leucorrhoea at the same time be present, cold-water injections will 
be found equally efficacious for that. In the large liquid evacuations 
which follow the first cold-water clysters, such a countless number of 
oxyures is sometimes found, that the liquid faeces are kept in a con- 
stant state of agitation by the swarm of animals. 

(4.) Trichocephalus dispar never produce any symptoms, and are 
scarcely ever seen in the evacuations, but always observed accidental- 
ly at the autopsy ; a description of the method of expelling them is 
therefore imDossible and unnecessarv. 

Y..—L1VEB. 

The liver is comparatively much larger in the new-bom child than 
the yearling. Frerichs, however, is unable to confirm the assertions 
of Portal and Meckel, according to whom the hver should be one- 
fourth heavier in the new-born child than at eight to ten months. 
That author found that the weight of the liver in comparison to the 
whole body is 

As 1 : lY in a seven months' foetus, 
" 1 : 28 in a new-born child, 
" 1 ■ 24 " " " " " 
u 1. 20 " " " " " 
" 1 : 33 in a child sixteen months old. 
14 



210 DISEASES OF CHILDREN. 

The average weiglit of tlie liver of a nevv-born cliild is 100 
grammes, but that of a child one and three-quarter years old is 250 
grammes, so that any actual decrease of the structure of this organ is 
altogether out of the question. 

The physical examination of the hver in children is conducted 
very much upon the same principle as in the adult. It is first per- 
cussed in the axillary line (a perpendicular line drawn from the ax- 
illary cavity downward), then in the mammillary line (a perpendicu- 
lar one drawn from the nipple downward), and finally in the sternal 
line (a perpendicular one from the sternum outward). By the first 
two lines, the diameter of the right lobe, by the last, that of the left 
lobe, of the liver is ascertained. 

This percussion is rendered very difficult by the restlessness of 
small children, and, in the examination of the jDOsition of the liver, al- 
lowance must especially be made for the very important influence 
of the respiratory acts. Older children, from the third year upward, 
may, by friendly coaxing, be induced to allow themselves to be ex- 
amined as quietly as adults. 

Diseases of the liver are extremely rare in young children. As 
we have already described icterus neonatorum in the chapter on the 
diseases originating directly after the delivery, there remain only the 
syphilitic and fatty livers, and the congenital anomalies of the liver, 
to speak of. The other hepatic diseases, cirrhosis, carcinoma, and 
echinococcus, are very seldom met with in children, and, when they 
do occur, their symptoms difi'er in no respect from those of thQ, adult. 
Acute hepatic atrophy, so far as I am aware, has never been observed 
in children. 

(1.) Syphilitic IxPLAiiiiATiox of the Ltvee. — Bayer and Ricord 
were the first who pointed out the connection between a peculiar 
morbid alteration of the liver and secondary syphilis, but Dittrich 
established it satisfactorily by a number of more accurate investiga- 
tions. In general, however, the disease is very rare. I have dissected 
many children with hereditary sj^hiKs (perhaps fifteen), and al- 
ways carefully examined the hver, but only once found this morbid 
condition. 

Pathological Anatomy. — At the autopsy of children ^vith con- 
genital syphilis, almost all of whom, as is well known, perish, a pecu- 
liar kind of inflammation, which attacks the glandular substance of the 
liver, is sometimes found. The exudation of this inflammatory pro- 
cess is partly plastic, and at a later period becomes transformed into 
cicatricial tissue. It, however, rarely reaches this condition in chil- 
dren, for death usually ensues too early. This exudation is composed 
of sero-plastic material, and therefore absorbable, and of a graj-ish or 



DISEASES OF THE DIGESTIVE APPARATUS. 211 

jellowisli mass, wliicli exhibits, microscopically, elementary granules, 
oil-globiiles, and only a few liver-cells. This yellowish-gray material, 
when the process has lasted long enough, is found in masses of the 
size of a hemp-seed, or of a pea, and circumscribed by the plastic sub- 
stance, which subsequently becomes cicatricial. When these morbid 
changes occur at many points of the liver, it thereby acquires an un- 
even, roughened appearance, and the peritoneal covering, if the mor- 
bid alteration takes place on its superficial surface, becomes indurated 
and callous. The free spaces of the liver in children, as a rule, are 
normal ; in adults, cirrhosis, carcinoma, and nutmeg or fatty liver, may 
occur along with the affection under consideration. 

In young children, the form of the liver is rarely changed by this 
disease ; usually nothing is found but a few spots, which, on section, 
prove to be firmer than the normal tissues, have a pale color, and 
are composed of gTanules, oil-globules, and only a few liver-cells. 

Symptoms and Therapeutics. — The special symptoms belonging 
to hver-disease are slightly marked and difficult to recognize. These 
imfortunate children, who usually are two or three months old, bear 
upon them the signs of hereditary syphilis, such as condylomatous ex- 
crescences around the anus and at the angles of the mouth, ulcers 
about the mouth, ozoena and a syphilitic exanthema. The nutrition is 
very imperfect, and the emaciation extreme. The upper surface of the 
Uver may possibly be found irregular or nodular, and its free border in 
some places slightly thickened and more rounded than in health. 

The minor alterations of the liver are, of course, totally indistin- 
guishable, and cannot be diagnosticated. As a complication, we may 
mention fibrous degeneration of the kidney, followed by anasarca. 
The most remarkable feature about this disease of the liver is, that 
icterus never occurs with it, but a grayish earthy hue of the skin su- 
pervenes on approaching dissolution. 

No special treatment can be recommended for this condition. All 
those children whd are not fed at the breast of their own mothers, and, 
on account of their liability to inoculate any other woman, cannot get 
a wet-nurse, almost invariably perish, no matter whether their livers 
are affected at the same time or not. The inunction treatment, where 
the state of the skin allows it, offers the best means thus far known 
for a recovery. This subject will be found more fully treated under 
Therapeutics of Syphilis. 

(2.) The Fatty Liver [Ilepar Adiposum). — By fatty hver we 
understand a greater quantity of fat in the hepatic cells than is nor- 
mally present, and always in such amount that distinct alterations of 



212 DISEASES OF CHILDREN. 

color of the parenchyma take place. This change of color is an im- 
portant feature, because, if observed and regarded, we avoid the error 
of supposing that a few liver-cells containing oil, such as may be 
found in every post-Tnortem examination, must be considered fatty de- 
generation. In the infantile organism, fatty liver is a tolerably fre- 
quent accompaniment of consumptive diseases, especially of pulmonary 
tuberculosis and of protracted intestinal catarrh. 

An attempt has been made to explain its origin in tuberculosis in 
various ways, and most authors are inclined to the view that in this in- 
stance it is produced by the embarrassed respiration, in consequence of 
which the oxidation of the hydro-carbons and fat cannot properly 
progress. But Frerichs very correctly observes that very many more 
decided distm-bances of the respiration, pulmonary emphysema, for in- 
stance, do not induce fatty livers, and that, on the other hand, in other 
tuberculous diseases, such as tuberculosis of the bones, in which the 
lungs may be totally unimpaired, the fatty liver may also be found 
present. 

He believes, therefore, that here the cause must be sought in the 
altered state of the blood that supervenes during the process of ema- 
ciation, and wliich consists in its becoming overloaded with fat, which 
in the progressive emaciation is absorbed. Hence the fatty liver is 
more marked in pulmonary tuberculosis than in other consumptive 
diseases, because in unimpaired lungs a greater consumption of oxygen 
takes place, and consequently a more rapid transposition of the excess 
of fat in the blood is effected. 

Pathological Anatomy. — A well-marked fatty liver has a larger 
surface than the normal organ, is flattened, and its margins are thick- 
ened and rounded. Its upper surface is smooth, glistening, whitened, 
and has a doughy feel ; the pressure of the finger leaves an imjDress. 
In color it is yellowish red or pale yellow, and a dry, slightly-wanned 
blade of a knife becomes coated with fat when dra^vn through its sub- 
stance. The quantity of fat, as ascertained by analysis, is very con- 
siderable. In one case Frerichs found 78 per cent, in the dried sub- 
stance of the liver ; in the fresh state, the same liver contained 43.84 
fat, 43.84 water, and 12.32 tissues, cells, vessels, etc. Simultaneously, 
the normal quantity of the water of the fatty liver becomes diminished, 
and may fall from 76 per cent, down to 43 per cent. The fat consists 
of olein, margarin, and traces of cholesterin. 

In less-marked cases these pathological characteristics are also less 
distinct. As the hepatic lobules always become affected in such a 
manner that the cells lying on the periphery of each lobule first un- 
dergo fatty degeneration, while the centre of the lobule, about the he- 
patic veins still remains free and of a normal color, a reticulated ap- 



DISEASES OF THE DIGESTIVE APPARATUS. 213 

« 

pearance o£ the incised parenchymatous structure is produced, called 
the nutmeg-liver. 

The brownish-red and pale-yellow substances alternate in such a 
manner, that the first forms small islands, which are surrounded by the 
latter hke a bright-yellow zone. The form of the brown islands de- 
pends upon the direction in which the lobules have been cut through. 
Where the central veins have been cut through transversely, they 
are round; where the incision falls parallel with the central veins, 
they will represent oblong or leaf-hke figures. 

The deposition of fat does not always take place in all parts 
of the liver alike, hence the islands difi'er in size, especially those near 
the surface of the liver, where they may be scarcely changed from the 
normal appearance. 

The microscopic a23pearance is very characteristic. The morbid 
change is limited to the liver-cells only, and no free fat is ever found 
in the intercellular spaces of the parenchyma. The hepatic cells, 
which, in the normal condition, are but slightly granular, exhibit at first 
fine, minute oil-drops within their walls, which, increasing in number, at 
length become confluent, and obscure the primitive cell-granules. The 
normal constituents of the cell thus obscured may be again rendered 
visible by removing the newly-deposited fat by the addition of oil of 
turpentine. The form of these fat-loaded cells is generally roundish, 
their angles having disappeared. 

As regards the remaining functions of the liver, it is remarkable how 
little they are disturbed. The sugar-generating function of the liver, 
a modem discovery, but now well understood and appreciated, does 
not become deranged, nor does the bile it secretes deviate in quality 
or quantity from the composition of the normal fluid. 

It is very difiicult to define the boundaries between the physio- 
logical and pathological fatty liver, as it is met with in almost all 
nurslings, from whatever disease they may have died. All young 
animals who are still nursing usually furnish the same condition. 

The disappearance of the fatty liver, as the age of the animal in- 
creases, is proof positive that the fat-infiltrated cells do not become 
destroyed, but that the liver becomes normal by a disappearance of 
the fat, and that therefore the fatty Hver, under certain circumstances, 
may also be ciirahle. The most frequent pathological conditions with 
which fatty liver associates are : tuberculosis, next rachitis, then here- 
ditary syphilis ; and, lastly, those diseases which lead to atrophy, 
such as enteritis folliculosa, diphtheritis, acute exanthemata, and ty- 
phus fever. 

Symptoms and Treatment. — It may have been concluded, from 
what has been already said, that the symptoms of this condition are 



214 DISEASES OF CHILDREN. 

very uncertain and unreliable. An enlargement of the dulness in the 
hepatic region is the first cardinal point in the diagnosis, although ab- 
sence of this sign has no conclusive significance whatever ; for in 
many instances a decidedly fatty liver is found without the least in- 
crease in volume. The fatty liver, however, does frequently become 
enlarged, flattened, and 23ushed forward against the abdominal vfalls, 
where it may be discovered by palpation and percussion. Such 
cases also present the condition called abdominal plethora, which con- 
sists in abdominal gaseous development, giving rise to flatulence 
and disposition to diarrhoea. The diagnosis becomes most probable 
when the above-mentioned diseases, tuberculosis, etc., have existed 
or still exist. 

The fatty liver of children will hardly ever become the object 
of direct treatment. When it is possible to remove the condition 
which caused it, it will disappear spontaneously; if not, there is 
no remedy that will exercise a direct influence upon the fat of the 
liver. 

(3.) Co^q-GENiTAL A:n"Omalies. — The malformations of the liver 
are either very insignificant, simply afi"ecting its form, or they may 
afiect its organization so seriously as to compromise the life of the in- 
fant. As regards the deviations from the normal form, we have a 
quadrangular, triangular, flat, or round form ; the division of the lobes 
may either be absent altogether or multiphed. As regards the great 
anomalies, we may mention, first of all, the total absence of the liver 
in monsters, especially acephalise. In diplogenetic monsters a double 
organ is also present. Similar malformations are observed in the gall- 
bladder and ductus choledochus. In congenital fissure of the diaphragm, 
which, on the whole, very rarely occurs on the right side, the liver 
may mount up into the right pleural ca^dty, and in congenital rupture 
of the umbihcal cord (vide p. 63) it may lie exposed through the ab- 
dominal fissure. 

In congenital transposition of the viscera the liver lies in the left 
hypochondrium, and with this a total or partial transposition of the 
rest of the abdominal and thoracic viscera is always combined. The . 
spleen, as a rule, is cut up into small spleens, which lie in the right 
hyponchondrium ; the cardiac orifice of the stomach on the right, the 
pyloric on the left side, and the heart in the right thorax. 

Syrtl has seen this transposition of the liver and of the rest of 
the \dscera only four times. I have never yet met with it. The diag- 
nosis cannot by any means be difficult, if a due amount of judgment 
and care be exercised in the examination. 



DISEASES OF THE DIGESTIVE ArPARATUS. 215 



Idiopatliic, primary aifections of the spleen probably never occur 
in children, but in some acute diseases a secondary enlargement of this 
organ originates, such as has been more minutely described in typhus 
abdominalis. It is not as easy to detect an enlargement of the spleen 
in the child as in the adult, because children, up to the third year, 
are generally much averse to a protracted examina.tion of the splenic 
region. It is best to examine them in the dorsal or right lateral 
decubitus. A normal spleen can never be discovered by palpation ; 
and even the decidedly hypertrophied spleens are often so movable or 
so soft, especially in typhus fever, that they frequently escape detec- 
tion. The hard, indurated splenic tumor, found in advanced rachi- 
tis and in chronic intermittent fever, may be discovered by palpation, 
and, in subjects much emaciated, may even be seen pushing out the 
thin abdominal covering. It moves downward with every inspira- 
tion, and upward with every expiration. 

In moderate hypertrophy the spleen retains its oblique direction 
down-vvard and forward ; but, in chronic and more marked indura- 
tions, it ^vill assume a more vertical position in line with the body, 
as the ligament pericolicum, which in the normal condition gives it 
an oblique direction, gradually becomes elongated. The form of the 
spleen, wherever it can be felt, is very characteristic. It is an oblong 
oval, with blunt borders, and an indentation on the internal aspect 
at about the middle of the tumor. 

In the examination of the spleen by percussion, very gentle blows 
should be given, particularly when the intestines are tympanitically 
distended, because, by heavy blows, the tympanitic resonance of 
stomach and intestines is developed, and the splenic dulness is lost. 
This examination should be practised with the patients always in the 
same position, because variations of the posture alone produce de- 
cided changes in the dulness. In general, all those dull sounds of the 
splenic region, which in children under one year extend under the 
pleximeter, beyond the normal boundary, are to be considered patho- 
logical. In marked ascites, and in serous effusions into the left pleu- 
ral sac, the dulness of the spleen cannot be detected by percussion at 
all ; it also disappears in intense tympanitis, so that, even when the 
h}^ertrophy of the spleen is considerable, a perfectly sonorous tym- 
panitic percussion-sound may be heard over the corresponding spac^. 

Besides the occurrence of the splenic tumor in typhus fever, it is in- 



216 DISEASES OF CHILDREN. 

variably present in intermittent fever, and a description of the latter 
may therefore very properly follow here. 

Ixtek:^ittent Feyer [Fehris Intermittens). — Intermittent fever 
occurs just as often in yomig children as in adults. Cases are even 
recorded of infants being born with enlarged spleens, and suffering 
febrile paroxysms at the same hour in which the mothers had their par- 
oxysms during pregnancy. I have never met such a case ; the young- 
est child that I have had to treat for intermittent fever was eight 
weeks old. The symptoms to be presently described have refer- 
ence only to children under two years ; in older children the whole 
course is so characteristic, that every one who has once seen an adult 
suffering from a j)aroxysm of intermittent fever will immediately 
recognize it. 

The etiology of infantile intermittent is naturally the same at all 
ages. The fever is confined to certain locations, and is never observed 
in children who have not lived, or at least stopped for some time, in 
malarial regions. The most exhaustive treatise on the etiology of 
malarial affections is to be found in GriesingeT''s " Infecting Diseases " 
( y^irehoio's " Hand-book of Special Pathology "), in which the circum- 
stances of the quantity of the water of the earth, of the temperature, 
of the climate, etc., are discussed in detail. 

Symptoms. — In children, the quotidian type is the most frequent ; 
still the tertian, and even the quartan, also occur. The hour in which 
the attack comes on is not always the same; the paroxysm, how- 
ever, is always confined to a certain period of the day ; the morning, 
afternoon, or evening. As regards the attack itself, it is usually not 
fully developed, but rudimentary in one or more of its phenomena. 
Actual chills, it is true, occur, in which the children are seized with 
shivering, low moaning, collapse, and have blue lips and nails ; imme- 
diately after they become decidedly hot, have a dry skin, great thirst, 
and restlessness, and finally break out in a general perspiration, thus 
completing a perfect picture of an intermittent febrile paroxysm. As 
a rule, however, the symptoms are not so conspicuous, and often leave 
the malarial character to be divined by their recurrence every day, or 
every other day, at the same hour. The shivering chills are often to- 
tally absent, and a remarkable paleness of the skin, blueness of the 
nails and hps, discoloration around the eyes, cold extremities, and low 
whimperings, or slight convulsive twitchings of the facial muscles, are 
only present. The pulse does not become very much accelerated, but 
vefy small. Respiration is normal, as to frequency ; the breath does 
not become cool, nor does the temperature of the mouth sink in the 
least. During the various symptoms, representing the cold stage, 



DISEASES OF THE DIGESTIVE APPARATUS. 217 

children rarely pass any urine ; but, if they have partaken of much 
milk shortly before, they generally throw it up. This stage never 
lasts longer than one, or, at the most, one and a half hours. During 
it the child presents a most critical appearance, and the physician 
may seriously compromise his professional reputation if he should give 
a prognosis immediately after first beholding the child. I myself 
once committed such an error in the early course of my professional 
career. 

In the second stage the vessels of the skin become turgid, the face 
is flushed, the pulse harder and quicker than in the cold stage, the car- 
diac impulse stronger, and felt over a larger area. There is very great 
restlessness, the child cries aloud, and is frequently attacked by con- 
vulsions, conjointl}' with which the pupils become remarkably dilated. 
The urine and stools are retained. 

This condition may last from two to three hours, and is much more 
correctly observed and described by the mothers than the cold stage. 
But it is also often transient, lasting barely one-quarter of an hour. 
It is followed by a slight perspiration, the third stage. 

While the patients are awake the perspiration is not very well 
marked ; the skin, it is true, feels moist, but drops of sweat are very 
seldom seen upon it ; free perspiration takes place only when sleep 
ensues. The heat and redness of the face then diminish, the thirst 
decreases, and the urine is discharged tolerably dark in color. The 
pulse assumes again its normal condition, and the patients once more 
present all the signs of general good health. But, in the intervals of 
freedom from fever, they are seldom perfectly well; are generally 
very restless, have less appetite, and a sluggish, irregular digestion. 
The febrile paroxysms are frequently so little pronounced that an 
observation of several days is necessary in order to confirm the 
diagnosis. 

The intermittent-fever cachexia, in small children, is very soon es- 
tablished, as early as after one to two weeks, and is characterized by 
the following symptoms : 

Ancemia appears very rapidly, the color of the skin becomes per- 
fectly white, or turns to a slight grayish tint, the lips and mucous 
membrane become pale, the emaciation progresses and becomes 
marked, slight oedematous swellings form under the eyes, the en- 
larged spleen is easily felt, and, when the emaciation increases, may 
even be seen. The liver also swells up, and its parenchyma becomes 
indurated (lardaceous liver). The intestines are tympanitic with gas, 
the stools are mostly diarrhoeal, and, in the last days of life, sometimes 
mixed with blood. The important discovery of the presence of brown 



218 DISEASES OF CHILDREN. 

or black granular pigment-matter in the blood of intermittent-fever 
patients is an attainment of pathological microscopy for which we are 
indebted to 'Virclioio and Meckel (Melansemia). This pigment is sel- 
dom found in the blood of children, because, for this purpose, it is 
necessary that the cachexia should be much prolonged, which, in chil- 
dren, is generally not the case, as they die of the disease too early. 
Moreover, intermittent fever is so easily recognized, and its treatment 
so rapid and eifective, that, wherever physicians are consulted for it, 
it seldom advances to the development of the cachexia. 

Pathological Anatomy. — In this country, a child rarely dies during 
the attack, but, in regions where pernicious fever prevails, death may 
occur even with the first paroxysm. The anatomo-pathological con- 
dition is then purely negative ; a sHght swelling of the spleen, with 
a superabundant amount of blood in the whole venous system, are 
the only abnormities. But, in the bodies of infants who have perished 
from the cachexia of intermittent fever, various morbid changes are 
met with, such as anasarca and effusions into the serous cavities, 
lardaceous liver, large lardaceous spleen, with brown or black pigment- 
matter most profusely accumulated in the spleen, in the liver, in the 
brain, upon the mucous membrane, and in the kidneys, which are also 
frequently affected with Bright's disease. In such cases the urine 
found in the bladder is always albuminous, and casts may be seen, with 
the microscope, in its sediment. 

Treatment. — The attack itself, in our milder forms of intermittent 
fever, requires a not very energetic but an expectant treatment. For 
the cold stage, a high temperature and mild cutaneous irritants are 
sufficient, such as friction with a woollen rag, with spirits of camphor, 
or other excitants ; cool coverings, cold affusions to- the head, the ad- 
ministration of plenty of cold water, and, when convulsions occur, one 
or two drops of laudanum, answer for the hot stage. The sweating 
that ensues should be encouraged in every manner possible. During 
the apyrexia the children must be kept upon a very strict diet, 
and in a uniform temperature. In sulphate of quinia, however, we 
have a very efficacious remedy for the prevention of the recurrence of 
the paroxysms. In children under one year, one grain, given in one 
dose, is generally sufficient to arrest the attack. To older children, 
two to three grains are given. The addition of sugar to this dose, 
thereby increasing its bulk, with the view of improving its taste, is 
practically useless, if not disadvantageous, for the taste is not im- 
proved in the least. In young children it is almost always easy to 
administer this remedy. But older children, who are not trained to 
swallow powders wrapped in wafers, are often, notwithstanding their 
best intentions, unable to swallow them, or refuse to attempt it. In 



DISEASES OF THE DIGESTIVE APPARATUS. 219 

these cases, the employment of the remedy in the form of clysters 
may be practised ; the method is very efficient. 

A country-man, from a peat-moor, once brought his boy, five years 
old, to me, stating that he had suffered daily for six weeks from the 
fever, which the physician of his place was unable to cure, because 
it was totally impossible to administer quinine to the child. The boy 
was very anaemic, had a very large spleen, an indurated hver, marked 
ascites, traces of albumen in the urine, and slight oedema of the lower 
eyelids. I ordered him a ten-grain solution of quinine in one and 
a half ounces of water, and caused it to be administered in a clyster, 
in my presence, to which the child readily submitted. The man took 
him home to his moor again, and, although continually exposed to 
the malarial air, he had no further attacks, but, under a tonic treat- 
ment with 5" ifyicift. pomat.^ meat diet, and beer, completely regained 
his former health and spirits. 

When one dose of quinine is not sufficient, another must be ad- 
ministered during the next interval. The determination of the hour of 
administration, upon which great stress is laid by many physicians, 
seems to be less important in children than in adults. The main point 
is always for the quinine to be well and thoroughly absorbed, and 
therefore it is ad\dsable not to give it directly before or after a meal, 
and immediately before the appearance of the chill, because during it 
the digestion is interrupted. 

In our intermittent fever, quinine has never yet failed in my 
hands to perform its duty, and for that reason I have never had occa- 
sion to resort to arsenic in the treatment of this disease. Still I would 
not hesitate for a moment, in case of failure, to use it, since Fowler's 
solution is excellently well tolerated by children. If the cachexia 
is already developed, an after-treatment will be necessary. The best 
is the removal of the child from the malarial region to a dry, elevated 
residence. Where this is not practicable, we have to limit ourselves 
to iron and a meat diet, combined, in older children, with small quan- 
tities of beer. 

(i.—PERITONJEUM. 

Peeitoititis Acuta and Chrok"ica. — Peritonitis with sero-fibrin 
ous exudation not unfrequently occurs in the new-born child, and 
even in the foetus. In older children, on the contrary, it is very sel- 
dom seen, without it is traumatic and tuberculous, because, in these, 
the principal causes of peritonitis — intestinal perforations, and diseases 
of the female sexual organs — rarely, if ever, occur. 



220 DISEASES OF CHILDREN. 

Etiology. — All the forms of peritonitis that it has been customary 
to assume, in special pathology, are also observed in the new-bom 
child. The idiopathic is the rarest form, and is almost exclusively 
seen in the foetus ; the secondary is the most frequent, and the metas- 
tatic occurs in lying-in houses in which puerperal fever prevails. The 
latter forms cannot always be positively distinguished. The process 
takes its starting-point, in both, from the umbihcal vessels, which 
are filled with ichor, but whether the inflammation is simply extended 
to the contiguous peritonaeum, or whether this membrane, like other 
serous coats, becomes attacked by the pysemic process, is often impos- 
sible to decide. This kind of peritonitis, depending upon an ichorous 
navel, is only liable to occur so long' as the latter exists, six, or, at the 
utmost, eight weeks after birth. After that time, the traumatic form 
is only seen, such as that occurring after burns, and perforation of 
the stomach or bowels, or that resulting from an incarcerated hernia, 
or from intussusception. The tuberculous form may also be added. 

Symptoms. — In peritonitis of the new-born child, pressure upon 
the abdomen is always paiaful, so much so, that the sufferers will 
utter loud but abrupt cries, even at the slightest touch. They are not 
capable of crying continuously, because the employment of the ab- 
dominal muscles for this purpose augments the pain. They are most 
quiet when they are completely uncovered, so that the abdomen is 
free on all sides ; the legs are extended, and the thighs not drawn 
up against the belly, as is usually the case in colic, because the pains 
seem to become aggravated even by the contact of their own thighs. 
Older children suffering from peritonitis always maintain the dorsal 
decubitus, and cannot be induced to lie upon the one or the other 
side. A paretic state of the abdominal muscles is present in all cases, 
and a more marked tympanitis in consequence. In the new-born child 
fluctuation can never be felt, because (1) the exudation is a plastic 
membranosis, and (2) the tympanitic bowels press against the ab- 
dominal walls in such a manner that the fluid exudation when present 
is below and behind the bowels. 

Vomiting is much less regularly observed in peritonitis of children 
than in that of adults, and diarrhoea is oftener present than constipa- 
tion. The appetite is completely lost, but the thirst is great. If the 
peritonitis has reached the serous coat of the bladder, retention 
of urine will supervene, or a few drops only are discharged at a time, 
attended by severe pain. The febrile signs are always distinctly 
pronounced ; the skin is hot and dry, the pulse frequent and small, 
and the breathing rapid and superficial. The respiration is distin- 
guished from that of health by the circumstance that the diaphragm 
does not act at all, or but very little, while the pectoral muscles seek 



DISEASES OF THE DIGESTIVE APPARATUS. 221 

to produce the utmost possible dilatation of the thorax. But, since 
the proper inflation of the lungs cannot by any means be accom- 
pHshed by this kind of respiratory act, the children are compelled to 
execute one deep diaphragmatic inspiration for every ten to fifteen of 
those superficial ones, and this, being attended by pain, is accompanied 
by distortion of the face, and frequently by a pitiful cry. The color 
of the face is oftener pale than flushed ; convulsions occur here less 
frequently than in pneumonia. 

Peritonitis of the nursling, as a rule, terminates fatally after 
from one to three days. Tuberculous inflammation of the peritonasum 
of older children runs a longer course, and may even last for many 
months. But the lethal termination is also in this form almost 
unavoidable. 

Pathological Anatomy. — The peritonaeum exhibits at different 
places, especially on the contiguous surfaces of two intestinal coils, 
capillary injection and plastic exudation, by which complicated ad- 
hesions are produced. In peritonitis of the new-born child, which 
is due, almost invariably, to a phlebitis umbilicalis, the principal mor- 
bid alterations are found about the umbilical ring and on the concave 
surface of the liver, which, by plastic exudation, becomes agglutinated 
to the neighboring organs, the stomach, and large and small intestines. 
In the small pelvis some ounces of a purulent, sanious, or bloody 
fluid, are usually found. In the two cases of fetal peritonitis recorded 
by Millard, numerous tense bands and old adhesions were found 
present in the cadavers of the still-born infants. Lobular pneumonia 
is often present as a complication. 

The treatment of peritonitis, as may be gathered from what has 
been hitherto said, is a most unsatisfactory one. That resulting from 
phlebitis umbilicalis seems almost invariably to be fatal. The treat- 
ment, therefore, which secures rest, cleanliness of the navel, and the 
best possible sustaining measures, seems the only one indicated. In 
tuberculous peritonitis, hectic fever, as a rule, is present, and, as its 
subjugation is altogether out of the question, we have to be content 
with trying to remove the febrile symptoms by the aid of small doses 
of quinine and morphine. For the peritonitic pains I use warm moist 
compresses, which are covered by a piece of gutta-percha cloth, and 
this by a dry cloth. They are much cleaner and more convenient to 
apply than cataplasms, which, especially at night, become cold and 
hard, and possess at no time any superiority to the application recom- 
mended. Traumatic peritonitis does, indeed, tolerate an antiphlogis- 
tic treatment to the extent of fi*om three to twelve leeches, and, in 
case no diarrhoea be present, the addition of several doses of calomel, 
gr. ss. to j, during the day, till a green diarrhoea takes place. The 



222 DISEASES OF CHILDREN. 

warm-water compresses above described should always form part of 
this antiphlogistic treatment, for they afford the greatest relief. 
If the pains are very persistent, opium is also indicated, as it is in 
most painful diseases. 

(2.) Ascites. Htdeopsical Effusiojs- into the Peeitoneal 
Sac. — Ascites is never a primary affection, but always a mere symp- 
tom of some other constitutional or circulatory disturbance. In young 
children it is inconsiderable as to quantity, often only a few table- 
spoonfuls of serum being found at the autopsy. Thus, children who 
die from hereditary syphiHs, tuberculosis, marasmus, the effects of 
enteritis, from congenital malformation of the heart, or scleroma, have 
small serous effusions in the abdomen. Considerable, easily-demon- 
strable effusions occur only in children who are over one year of age, 
and generally as a result of scarlatina, or of intermittent fever, and 
occasionally, but less frequently, of abdominal t}^hus. 

Pathological Anatomy. — In old children the quantity of the as- 
citic fluid may reach several pounds. The color of the serum is a wine 
yellow ; sometuues a httle coloring matter of the blood is also mixed 
with it. The reddish color thus produced may, however, also be due 
to one or another of the cutaneous veins having been cut at the 
opening of the abdomen, and their contents escaping into the peri- 
toneal cavity. The chemical investigation gives a large percentage of 
albumen, and the salts as they are found in the serum of the blood. 
The peritonaeum is either perfectly normal, or at some places displays 
white opacities, which are principally observed in protracted cases of 
ascites. Occasionally one of the intestinal coils or the liver is coated 
with a thin layer of exudation, so that we have to deal here with a 
transition into true peritonitis. In no autopsy should the mere 
finding of ascites content us, but its cause, one of the above-men- 
tioned affections, should be sought for, in which the heart and kid- 
neys, in particular, are to be subjected to the most scrutinizing inves- 
tigation. 

Sjmiptoins. — The existence of ascites can only be satisfactorily 
proven by distinct fluctuation. Small efiusions can never be detected 
in the dorsal decubitus ; occasionally they may be discovered, by lapng 
the children on the right side, and slightly elevating the pelvis, where- 
by all the serum then gathers into the right hypochondrium. The 
smallest quantities, however, may be detected by laying the child upon 
its belly, and then causing it to be raised up, so that the navel will 
form the most depending part of the whole abdomen. x\s in this po- 
sition all the serum must gather round about the navel, it is then 
easily detected by percussion fi-om below upward. Fluctuation is 
ascertained. in this manner. The palmar surfaces of the fingers of one 



DISEASES OF THE DIGESTIVE APPAEATUS. 223 

hand are made to press against the abdominal parietes, while with 
the tips of the fingers of the other the abdomen is quickly and lightly 
struck at a point opposite to the pressing hand, or at least at a distance 
of a few inches from it. The undulation thus produced, in case fluid 
be present, between the pressing and the striking hands, communicates 
a peculiar thrill to the former. Besides being produced by the free 
fluid of ascites, fluctuation also originates from the presence of diar- 
rhoeal contents of the intestines, from a bladder filled and mounting 
over the symphysis, and even from oedema of the abdominal walls, 
which, especially in nephritis after scarlet fever, is commonly very in- 
tense. The latter, however, is readily distinguished from true ascites, 
by the pitting from the pressure of the finger, and by the superficial 
character of the flaccidity. The distended bladder is easily emptied, 
and the intestinal catarrh readily relieved by a mucilaginous diet and 
small doses of opium, whereupon the true state of afl'airs will become 
manifest. 

In mild grades of ascites, nothing can be discovered externally, 
and the circumference of the abdomen is not materially increased ; 
but in the higher grades attention is attracted to the size of the 
belly, even at the first sight. The integument is glistening and tense ; 
there is flatness on percussion of the lower part of the abdomen, the 
dulness extending over a large surface ; the umbilical ring is distended^ 
and the navel prominent. The pressure of the serum excites frequent 
inclinations to micturate, but only small quantities of urine are evacu- 
ated at a time. 

The general phenomena, loss of appetite, fever, respiratory dis- 
turbances, etc., correspond with the conditions causing the ascites. 
The patients, as a rule, perspire but little, and pass very small quan- 
tities of urine. It is mostly dark-colored, and, in nephritis, contains 
albumen and fibrous casts. The stools are often diarrhoeal. 

The prognosis does not depend upon the amount of the ascites, 
but upon its etiology. It may be regarded as unfavorable in almost 
all kinds of ascites, except in that originating after scarlatina, typhus 
fever, and hypertrophy of the spleen from febris intermittens. 

Treatment. — This, of course, varies according to the cause. The 
conditions which give rise to ascites are of such a hopeless nature, that 
any special treatment, except a stimulating regime^ will hardly be 
indicated. "When caused by nephritis, after scarlatina, rooh^ juni- 
peri, which children usually take very readily unmixed and un- 
diluted, is an excellent diuretic remedy; I direct one-half or a 
whole teaspoonful to be taken daily. It is also applicable in ascites 

* This is the succus spissatus juniperi of the European pharmaeopanas, and is 
somewhat stronger than a fluid extract. — Tr. 



224: DISEASES OF CHILDREN. 

after intermittent or typhus fever, but then a tonic treatment, con- 
sisting of a meat diet, beer, wine, and small doses of iron, is to be 
recommended in addition. The ascites which comes on after scarla- 
tina subsides more rapidly than any other. 

(3.) Morbid Alteeations of the Mesei^teeic Glaisds. — In all 
cases of enteritis foUiculosa, the mesenteric glands become hypertro- 
phied and indurated, and their impermeabihty most probably affects 
the atrophy that so frequently follows it, a detailed description of 
which has already been given in connection with that disease (p. 156). 
In addition, cheesy tubercles of the glands occur in older children ; and, 
in those who perished by typhus fever, hypertrophy, or small ab- 
scesses of single glands, are sometimes met with. 

The diseases of the mesenteric glands do not seem to give rise to 
any s^nnptoms, but the nutrition, if a large number of the glands is 
involved in the hj^pertrophy, suffers very quickly. The glands, on the 
whole, are so small, and the bowels are always too tympanitic, to 
allow them to be felt. 



CHAPTER III. 

DISEASES OF THE ORGAXS OF CIRCULATIOX. 

K.— HEART AND VASCULAR TRUNKS. 

(1.) CojfGEiaTAL An^omalies. — For the purpose of correctly un- 
derstanding the congenital anomalies of the heart, this much of the 
embryology has to be premised: that the heart and roots of the 
vessels at the commencement of development are not hoUow, but 
consist of a loose conglomerate mass of cells, without any chasm or 
channel, and without any cavities. At this period the heart still 
possesses the form of a straight cylinder, which above and below 
terminates in two prolongations ; the two lower prolongations, the 
venae omphalo-mesenterica, are the roots of the vessels which subse- 
quently ramify in the germinal vesicle and conduct the blood from it 
to the heart; the two upper prolongations are the two future first 
aortic arches, which, in the embryo, carry the blood from the heart. 
The external upper surface, according to Bischoff, very gradually 
becomes firmer by the cells being deposited closer to each other, and 
thus the walls are formed, and a cavity is developed within, in which 
the fluid and cells, forming the first trace of the blood, accumulate. 
The cardiac cylinder then assumes an S-like shape, and begins to 



DISEASES OF THE OEGANS OF CIRCULATION. 225 

contract and dilate in a slow rhjtlim, by wliich its fluid contents are 
propelled anteriorly and upwardly into the aortic arches, while that 
from the venous trunks, on the other hand, is sucked in from below 
and behind. 

By-and-by this cardiac canal, by various curvings, dilations, and 
constrictions of single parts, becomes the heart proper, consisting of 
the aortic dilatation, one ventricle and one auricle. The septa do not 
become developed till a later period, by which the right and left 
ventricle and auricle are formed. Imperfect development or faulty 
insertions of these partition-walls are the most frequent causes of mal- 
formation of the heart. 

Nevertheless, cases of malformation are also observed as the result 
of an embryonal inflammatory process of the muscle of the heart, and 
its consequent atrophy and cicatrizations. 

The best compilations on the congenital anomalies of the heart 
are to be found in the text-books of HoJcitansTcy and Bamherger^ 
which have furnished the basis for the following summary : 

(1.) Absence of the heart (acardia) occurs only in monstrosities, 
where the upper half of the trunk is at the same time wanting, and 
the nervous system consequently exists only in a rudimentary form. 
The converse of this is the duplex heart in double malformations 
(diplogenesis) ; this occurs especially in doubling of the upjDer half 
of the body, where two completely-separated hearts either occupy 
each a separate pericardium or a common one. 

(2.) Abnormal situation of the heart. — Here we may have the 
foetal heart occupying a central position in the thorax, or transposed^ 
so that the cardiac impulse is felt at the right of the sternum. In 
this latter case we have generally an accompanying displacement of 
other organs, particularly the liver and stomach. 

Again, the sternum may be absent and the integument wanting, 
and when this condition occurs we have the heart entirely exposed, or 
merely covered by the pericardium. 

If a greater portion of the thoracic and abdominal walls is want- 
ing, we have the condition called eventration, in which the abdominal 
organs lie without the body. 

In very rare instances a defect or splitting of the diaphragm occiu's, 
and the heart then penetrates through this opening into the abdominal 
cavity. 

(3.) Abnormal shape and size. — Variations of the shape of the 
heart are often devoid of importance. It may be broad, cylindrical, 
or fissured at the apex. A pointed and a round heart may perform 
its functions naturally, whereas, on the contrary, abnormal bigness or 
smallness of the whole heart, or some of its parts, is complicated with 
15 



226 DISEASES OF CHILDREN. 

functional disturbances. The right ventricle is most frequently found 
enlarged in consequence of the fostal circulatory passages having re- 
mained open. 

(4.) Abnormal formation of individual parts of the heart. — Here 
we meet with abnormities {a) of the septa^ {h) of the roots of the 
vessels, and (c) of the ostia (orifices) and valves. 

[a.) If the formation of the septa has failed to take place, there 
will be but one ventricle and 07ie auricle. Generally, however, the 
septa are indicated by projecting bands, or are fully developed in 
one or the other chambers, so that there may be two completely sep- 
arated auricles and only one ventricle, or vice versa. As the foramen 
ovale, even in the physiological state, at first furnished a small com- 
munication between both auricles, so do we also here find the most 
frequent defects. It also happens, sometimes, that the left auricle 
communicates with the right ventricle, or, vice versa, through an 
oblique communicating passage. Most of the cases are then also 
complicated with extensive defects of the septa and faulty origin of 
the roots of the large vessels, which may also be produced by the 
insertions of the septa having left the median line. It thereby be- 
comes possible for the inferior A^ena cava to terminate in the left 
instead of the right auricle, or for the aorta to originate from the right 
side of the heart. 

{h.) As has been already stated, abnormities of the roots of 
the vessels depend, in a great measure, upon an imperfect develop- 
ment or faulty insertion of the septa. The most frequent devia- 
tions are : 

(1.) The pulmonary artery is either entirely absent, or is very 
much constricted at its origin, and only becomes dilated beyond the 
duct, arter. Botalli, which conducts the blood to it from the aorta. 
When there is only one ventricle, the aorta supplies the place of the 
pulmonary artery. 

(2.) What has been said of the pulmonary artery may also happen 
with the aorta — it may be misshaped or completely closed ; it then 
receives its blood from the pervious remaining ductus Botalli. 

(3.) The fetal type of the distribution of the blood is wholly 
retained, the aorta supplying the upper half of the body with blood, 
and the pulmonary artery, through the Botallian passage, the lower 
half of the body. 

(4r.) A transposition of the large vessels has taken place, the aorta 
springing from the right, the pulmonary artery from the left ventricle. 

(5.) Both vessels originate from one ventricle. 

(6.) The aorta has two equal or unequal roots, one of which 
springs from the left, the other from the right ventricle. 



DISEASES OF THE ORGANS OF CIRCULATION. 227 

(7.) The bulb of the aorta is immensely enlarged and represents a 
third ventricle. 

(8.) The ductus Botalli often remains permeable, or is absent 
altogether, or may become developed into a permanent vascular 
trunk. 

The partial occlusion of the aorta at the other side of the opening 
of the Botallian passage deserves a more detailed description, an 
anomaly which has been closely investigated, especially by RoMtansky. 
A great constriction of the aorta occurs at this place, which may be 
but a few lines in length, and then terminates in an aorta descendens 
of a perfectly normal calibre. This anomaly is produced by the arteria 
pulmonalis in the foetus forming an arch, is continued in the descend- 
ing aorta, while the blood of the aorta is only transmitted into the 
arteries of the head and arms, the innominata, carotids, and subclavia 
sinistra. The blood of the pulmonary artery flows through the wide 
duct. Botalli into the aorta. A narrow vascular piece runs to the arch 
of the pulmonary artery, which may be regarded as a continuation of 
the aorta, and is described under the name of isthmus aortse. After 
birth, the course of the blood is deviated from the duct. Botalli by 
the dilatation of the lungs ; that passage soon becomes impermeable 
and obsolete, and, at the same time, the originally narrow vascular 
piece, the isthmus aortge, becomes dilated to the diameter of the nor- 
mal aorta. Now, if this dilatation of the aorta does not take place 
after birth, and the Botallian canal nevertheless becomes obliterated, 
a permanent constriction of the isthmus aortae will be the result. 

A collateral circulation then forms for the blood from the left side 
of the heart, the road for which to the lower half of the body has thus 
become obstructed, by which that section of the aorta below the con- 
striction is nevertheless filled with blood. For this purpose, the 
branches of the subclavian artery become dilated, and assume a ser- 
pentine course. The most important branches which enter into the 
formation of this new connection are : the internal mammary, the rami 
intercostales, which conduct the blood into the rami intercostales pos- 
teriores, anastomosing with them, and which originate from, or, more 
correctly speaking in this case, terminate in the descending aorta. 
Further, the anastomoses between the internal mammary, superior 
epigastric, and the lumbar arteries ; next the arteria intercostales 
suprema with the intercostal branches of the mammary ; and, lastly, 
the arter. dorsalis scapulae with the dorsal branches of the intercostal 
arteries. 

In this manner, the descending aorta becomes completely filled ; 
still it never acquires the normal calibre, whereas the arch of the aorta 
up to the place of constriction is seen to have become completely 



228 DISEASES OF CHILDREX. 

dilated. These individuals are perfectly capable of living many 
years. 

(9.) The venous terminations in the auricles may be transposed in 
the same manner as in the case of the arteries with the ventricles, or 
the vena cava and the pulmonary veins terminate in one auricle only, 
etc. 

(c.) Congenital abnormities of the valves, and ostia in general, are 
comparatively rare, and can more readily be attributed to fetal inflam- 
matory processes, fetal myocarditis, than to an actual arrest of devel- 
opment. The most frequent occurrences are : 

(1.) Stenosis of the conus of the pulmonary artery, or of the aorta, 
a condition in which the muscular structure forming the conus has 
become converted into a white callous mass. This stenosis occurs 
more frequently at the pulmonary artery than at the aorta, and, ac- 
cording to £amherge)\ is one of the most frequent causes of congenital 
cyanosis. The foramen is invariably found open, or the septum of the 
ventricle has not even become completely developed. 

(2.) The valves may be cartilaginous, hypertrophied, or the auric- 
ulo-ventricular valve thickened, and numerous columnas papillaries, 
and falsely-inserted chordge tendinse, occur ; or, on the contrary, the 
valves are transparent, very much attenuated and perforated. In 
rudimentary construction of the large arteries or false insertion of 
the septa, the tricuspid or semilunar valves may also be completely 
absent. 

(3.) The valve of the foramen ovale may be absent altogether, or 
become prematurely closed ; various malformations have already been 
observed on the Eustachian valve too. 

Symptoms. — Numerous descriptions of the congenital malforma- 
tions of the circulatory apparatus are to be found in the dissertations 
and larger monographs, but the symptoms accompanying them are sel- 
dom pictured sufficiently in detail, and, even where this is the case, they 
will be found, as a rule, not to harmonize in one and the same ana- 
tomical condition. According to Bamberger, all the malformations in 
reference to their symptoms may be comprised in three groups : 

(1.) To the first group all the malformations belong which pro- 
duce an absolute incapacity for living, such as monstrosities, ectopia of 
the heart, with absence of the integument, complete univentricular 
heart, and transposition of the large vessels. 

(2.) In the second group may be included all those malformations 
with which children may indeed live, and laboriously or even nor- 
mally continue to develop throughout the first few years, still mth every 
additional year they experience an aggravation of their disturbances 
of the circulation, so that death ensues in the course of the first, at 



DISEASES OF THE ORGANS OF CIRCULATIOX. 229 

the latest in that of the second dentition. To this class belong con- 
genital constriction of the conns of the pulmonary artery, and that of 
the aorta, extensive communications of the ventricles, or of the auri- 
cles, or of a ventricle with its opposite auricle, the origin of the aorta 
from both ventricles, and the remaining previous state of the duct. 
Botalli. 

(3.) There is a number of minor anomalies, by which the circula- 
tion is in no way impeded, and consequently no hinderance whatever 
is offered to the development of the child. To this group belong par- 
ticularly the external alterations in the form of the heart, the splitting 
of the cardiac apex, and the conical, cylindrical, broad, and circular 
form. The transposition of the heart to the right side, generally com- 
phcated ^vith transposition of the liver and stomach, is devoid of 
any influence upon the continuation of life. The remaining open of 
the foramen ovale is likewise entirely unimportant, as has already been 
proven by numerous post-mortem examinations, nor is there the least 
plausibility for regarding it as the cause of cyanosis, to which, how- 
ever, we will recur once more, further on. 

The time of the appearance of symptoms is extremely variable. 
It is certainly true that the disturbances of the circulation produced 
by congenital defects of the heart may, at first, be insignificant, and 
may very gradually increase from month to month, but the state- 
ments of some authors seem very improbable, who maintain that con- 
genital defects of the heart do not give rise to any symptoms till 
after many years, even not till after puberty. Those authors un- 
doubtedly have fallen into some error, and certain acute diseases of 
the heart have been overlooked. Many children, on the whole, have 
displayed the most distinct signs of marked disturbances of the cir- 
culation immediately after birth. They come asphyxiated into the 
world, and soon after perish by atelectasis of the lungs. They cry but 
lowly and discontinuously, are always cool, somewhat cyanotic, sleep 
a great deal, and suffer from convulsive attacks of coughing, by which 
the cyanosis rapidly increases, and the protruded tongue especially 
assumes a dark, bluish-red color. 

Cyanosis is always the most constant and reliable symptom, but 
concerning its origin partially incorrect views still exist. Formerly, 
it was assumed that cyanosis in congenital malformations of the heart 
was produced by the mixing of arterial and venous blood, as thus, 
when dark-red blood, in the normal condition, found its way into 
the arterial system of vessels. That this view is incorrect is seen 
from the forms of cyanosis, in which the anatomical conditions of the 
heart are perfectly normal, for example, in cholera or in poisoning 
with carbonic-oxide gas. In these cases, as is well known, the cyano- 



230 DISEASES OF CHILDREN. 

sis is of an intense degree, and yet no traces of any morbid lesions 
are found about the heart at the post-mortem examination. The 
foramen ovale, on account of this same fallacious supposition, has also 
received altogether too much attention, and it was a matter of no con- 
sequence, when a probe could be passed from one auricle into the 
other, whether the valve was perfect or not. 

The only test-bearing reason for the cyanosis is to be found in an 
imperfect oxidation of the blood in the lungs, combined with a stasis 
in the peripheral venous system. But this process may be produced 
by various conditions ; either an impediment exists at the left side of 
the heart, and conjointly with this there is stagnation of the blood in 
the pulmonary veins, or the supply of blood to the lungs is diminished 
in consequence of a stasis in the right side of the heart, and hence 
less blood is arterialized, or the circulation meets with impediments 
in the lungs, the effects of structural lesions, or, lastly, the inhaled air 
is poor in oxygen, and in that case the blood is likewise but imper- 
fectly oxidized. The blood may also become so altered in consistency 
that its flow will thereby be retarded, and this is especially applicable 
to the inspissation of the blood in cholera. Thus we see that the 
causations of cyanosis are tolerably numerous, and are by no means 
solely to be sought for in mechanical alterations of the heart. 

The degrees of cyanosis vary exceedingly, and fluctuate between a 
slight bluish discoloration of the lower eyelids and a bluish redness of 
the whole body, and all supervening congestions produce an aggrava- 
tion of the existing cyanosis. Too high and too low temperatures, 
excitement, crying, laughing, bodily exertions, are therefore the most 
frequent causes of this aggravation. 

When children with congenital malformations of the heart survive 
the first few years, various other symptoms of disturbance of the cir- 
culation become superadded. Almost all of them suffer from imper- 
fectly-developed pectoral muscles and pigeon-breast. The extremities 
are always cold and moist, very much like the skin of a frog, the tips 
of the fingers swell up bulbous, over which the nails, curved like claws, 
project ; the cutaneous veins are preternaturally large ; the patients 
are unable to exert themselves in any manner, whether to run or 
climb, or to cry continuously, for all these efforts cause them severe 
pain in the prascordia, dyspnoea and palpitations. Haemoptysis, also, 
in rare instances, is observed in larger children ; epistaxis, on the con- 
trary, is a symptom which occurs tolerably often, and as a rule gives 
momentary relief. Finally, general dropsy of the cellular tissues and 
of the serous sacs, with which albuminuria becomes associated, ter- 
minates the distressful existence of these children. 

The physical examination of congenital cardiac malformations is 



DISEASES OF THE ORGANS OF CIRCULATION. 231 

attended by extraordinary difficulties. Hypertrophy of the heart is 
almost unexceptionably demonstrable, and is usually due to a marked 
enlargement of the right side of the heart. In this condition the 
heart's impulse is felt over a larger space, and stronger than usual. 
Distinct cardiac murmurs can seldom be elicited by auscultation ; in 
most instances a confused sound is only heard instead of the one or 
the other, or even in place of both cardiac sounds. Prolonged loud 
murmurs allow one to conjecture the existence of a marked abnormal 
communication between the cardiac moieties, a perforation of the sep- 
tum for example ; a strong systolic murmur heard most distinctly over 
the pulmonary artery indicates a constriction of this vessel, one of the 
most common malformations that occur. Sometimes, however, the aus- 
cultatory phenomenon is not adaptable to the one or to the other evil, 
and no nearer approach to an accurate diagnosis can be made than of 
congenital defect in general. The periods of the first and second 
dentition, according to statistical compilations by Friedherg and Ah- 
erle, are especially dangerous for children with congenital defects of 
the heart. Out of 139 cases, 53 died in the first year, 51 between 
the second and eleventh year, 30 between the eleventh and twenty- 
fifth, and 5 only attained to an age of over forty-four years. 

Treatment. — A direct treatment, of course, is altogether out of the 
question ; we have to limit our efi'orts to the prevention of all possible 
injuries, and to institute an appropriate dietetic regime. The restric- 
tions concerning the necessary rest are easily enforced in these chil- 
dren, for they are soon taught by experience how injurious and pain- 
ful any accelerated action of the heart is to them. As regards the 
diet, no particular precautionary measures need be prescribed; all 
heating and alcoholic drinks, however, must be absolutely prohibited. 
Warm clothing is extremely advantageous in these cases, and a flan- 
nel shirt should therefore be particularly recommended to be worn 
next the skin. All antiphlogistic treatment, with calomel, leeches, 
cantharides, etc., must under all circumstances be avoided, for dropsy 
and the fatal end are perceptibly accelerated by it. Active conges- 
tions, which in these cases are liable to occur extremely often, must be 
relieved by the external application of cold, acidulous drinks, and 
strict diet. 

If the children come asphyxiated into the world, the methods of 
animation already recommended for asphyxia should be resorted to, 
but in these cases they almost always prove fruitless. 

(2.) Endocaeditis, Peeicaeditis, and Rheumatismus Acutfs. — 
We include here three morbid pictures in one frame, which anatomo- 
pathologically have no similarities whatever to each other ; clinically, 
however, they can scarcely be separated, if it is desired to avoid the 



232 DISEASES OF CHILDREN. 

numerous repetitions which must occur in describing the individual 
alterations separately. Added to this, these morbid conditions are 
extremely rare in children, and it hardly seems necessary to give a 
very exhaustive account of them. 

Symptoms. — We commence with the symptoms of acute rheuma- 
tism, and then allow the most frequent complications, endo- and peri- 
carditis, to follow : 

Hheumatismus acutiis. — Acute rheumatism of childi^en differs but 
little from that of the adult, only its course is shorter, and the affec- 
tion, as a rule, less intense. The youngest child that I have had to 
treat, for well-marked acute rheumatism, with endocarditis, was one 
year and nine months old, and after three months succumbed to dis- 
ease of the heart. This is a very rare case, for in all the text-books it 
is stated that children of six years and over are only liable to 
this disease. Many affections, which by the laity are denominated 
by the vague name of " growing fever " (Wachsfieber), belong to this 
condition. 

Intense fever is always present at first, the skin becomes burning 
hot, the thirst great, the pulse enormously accelerated, and great rest- 
lessness and sleeplessness supervene. This intense fever at the ut- 
most lasts eight to ten days ; it then gradually subsides, and only 
when pernicious complications have become superadded, particularly 
affections of the heart, will it continue for an indefinite time and with- 
out interruption. In most instances the patients are very pale and 
collapsed, have a remarkably sad, painfiil expression of countenance, 
and a lethargic appearance ; they keep the affected joint in the ut- 
most possible state of quiescence, while the free extremities, on ac- 
count of the intense fever-heat, are incessantly restless and agitated. 

The essentiality of the disease consists in a swelling of the vari- 
ous joints, predominantly those of the lower extremities, which are 
affected in the same manner as in the adult. Touching and still 
more the moving of the diseased members is extremely painful, and 
the patients, with an expression of the utmost anxiety in their coun- 
tenances, ^^'ill guard over and admonish against every approach to the 
painful joint. The swollen parts are always reddened at first; the 
redness, however, disappears before the tumidity does. The knee-joints 
are most fi-equently affected, next in order of frequency follow the 
joints of the ankles, then those of the upper extremities, and lastly the 
spinal column. 

These swellings of the joints never pass over into suppuration ; 
they abate completely, and disappear without lea\^ng any traces of 
the disease behind them ; in some instances a slight weakness and 
painfulness, on using the extremity, will be the only evidences of the 



DISEASES OF THE ORGANS OF CIRCULATION. 233 

previous existence of tlie malady. The pathognomonic sign of the 
affection is its wandering, or its alternating, from one joint to the 
other. Only extremely rarely is the process completed with the simul- 
taneous implication of several joints ; usually, in a few days after the 
swelKng of the joints first affected has declined, new ones will be at- 
tacked with the same severity and run a similar course, and this may 
be succeeded by a second and even a third accession. 

The general symptoms correspond to the severity of the fever. The 
appetite is very much abridged, or completely gone, the stools are re- 
tained, the urine is dark-colored, rich in uric acid, and voided in small 
quantities only. The patients perspire very much, and are thickly 
studded with miliaries. 

The diagnosis of acute rheumatism is very easy, since it almost 
wholly attacks older children, who are already able to give a rational 
account of their sufferings. It can only be confounded, in its incipiency, 
with the prodroma of an exanthema, or with typhus fever, where also 
very severe pains in the knee and ankle joints occasionally occur. The 
latter, however, are recognized by the facts that the joints do not 
swell, and that slight pressure or passive motion does not particularly 
aggravate the pain, which is always the case in acute rheumatism. If 
it is at all possible to confound the disease under consideration with 
scrofulous artlu-ocace, with tumor albus, then this can only happen in 
its incipiency, and the error can continue but a few days, as no wander- 
ing of the malady from joint to joint occurs in the latter affection, and 
its course is of a totally different and chronic form. 

Simple acute rheumatism, without any complication, has a duration 
of fourteen days at the utmost. But when it is complicated with car- 
diac affections, as is the case with at least one-third of all the cases af- 
fected, its duration will then be indefinitely prolonged, and a fatal 
end ma}^ occur even after a sickness of many years. Under the head of 
complications (a.) Endocarditis and (b.) Pericarditis deserve a special 
consideration. 

(a.) Endocarditis. 

Pathological Anatomy. — The excellent investigations of Luschha 
have established the fact that the endocardium is composed of the 
same number of layers as the vessels. The superficial surface is formed 
by a thin stratum of pavement-epithelium, which must be regarded as 
the direct continuation of that of the vessels. Then follows a layer of 
extended longitudinal fibres ; next, one of very fine elastic fibres, which 
frequently interlace with each other, analogous to the contractile coat 
of the vessels ; and, finally, a layer of connective tissue unites this 
elastic coat with the muscles of the heart. The vessels and nerves are 



234: DISEASES OF CHILDREN. 

found almost entirely in this connective tissue, and are but little in con- 
tact with the elastic fibres, which accounts also for the circumstance that 
a true exudation can only take place in the former. The exudation, 
however, soon forces the super-lying coats aside, and makes its appear- 
ance in the cavity of the heart, on the other side ; it also attacks the 
subjacent layers of the cardiac muscle, so that a slight degree of myo- 
carditis always accompanies endocarditis. Red spots, according to 
JjiischJca^ are at first observed on tlie endocardium ; the superficial sur- 
face as yet is still perfectly smooth ; this smoothness, however, soon 
disapjDears, the superficial surface becomes rough, and now the exuda- 
tion under the microscope exhibits entire and destroyed epithelium- 
cells, exudation-corpuscles, and fibre-elements. The roughened places 
on the endocardium soon arrest some fringes of fibrine, from the on- 
w^ard-flowing current of blood, and thereby acquire a flocculent ap- 
pearance. This endocarditic exudation, according to Bamberger^ may 
undergo the following metamorphosis : 

(1.) The exudation may be completely absorbed ; this, however, 
only seems to be possible in very thin layers that have not yet pene- 
trated through the epithelium. 

(2.) In most instances it does not disappear entirely, but produces 
permanent alterations upon the inner surface of the heart. The most 
common morbid appearances of this kind met with are white con- 
densed places, a condition that has been called tendinous spots (Sehnen- 
flecke), which are always disposed to atrophy, and undergo cicatricial 
contraction, and now, in case these occur on the valves or in their im- 
mediate vicinity, will cause them to shrink or alter their attitude and 
insertions. Thus, endocarditis is the main cause of subsequent cardiac 
disease. In other cases, the endocarditic exudation has the dispo- 
sition to degenerate into polypoid extuberations, and then will pos- 
sess many 23oints of resemblance to pointed condylomata, and, in 
consequence thereof, have even been falsely regarded as true manifes- 
tations of syphilis. 

(3.) It has become evident, mainly through Vir choices indefatiga- 
ble researches, that some of the already coagulated portions of the ex- 
udation may also be torn ofi" from the endocardium, and washed away 
by the current of the blood, and in this manner thrombosis form in 
difi'erent parts of the body. The most common sites of these thrombi 
are in the spleen, next in the kidneys and brain. Death almost inva- 
riably ensues from such a displacement of the thrombi. 

Symptoms. — ^Yhen the endocarditic exudation is so deposited that 
it cannot materially influence any of the valves, it will not be possible 
to ascertain its existence by a physical examination ; moreover, the 
functional phenomena are so variable and so imperfectly described, even 



DISEASES OF THE ORGANS OF CIRCULATION. 235 

by large children, that it seems almost impossible to form a diagno- 
sis. Generally, however, extuberations form upon the valves, and then 
distinct physical alterations ensue. 

The left side of the heart is affected much oftener than the 
right ; and the mitral valve, in fact, most frequently of all. Not only 
the deposits upon the valve itself, but also those in the vicinity of the 
colunmEe earn?© and columnge papillares, are capable of producing a 
distortion of the valve, or causing it to atrophy, and thus effect its in- 
sufficiency. We therefore have, as the most common physical signs, a 
systolic murmur, in place of the first sound of the heart, heard with the 
greatest distmctness at the apex of the heart, less distinctly over the 
aorta, and not at all over the carotids. The right side of the heart 
soon becomes consecutively enlarged, so that the dulness in the prse- 
cordia extends over a larger space, and the heart's impulse is felt corre- 
spondingly stronger, and over a larger area. If the extuberations around 
the ostium venosum of the left ventricle * become very numerous, a 
stenosis will then also take place at this ostium, and thus produce a di- 
astolic murmur ; this condition, however, seems to be exceedingly rare. 

The semilunar valves of the aorta may likewise become involved 
in the endocarditic process, and, through shrinking and perforations, be- 
come insufficient. But, the more common phenomenon observed on 
these valves is, their becoming covered with vegetations, and thus giv- 
ing rise to a stenosis at the ostium arteriosum. A systolic murmur is 
likewise heard in this case, but it is most distinct over the aorta, 
and is plainly propagated into the carotids. 

The right side of the heart is much more rarely attacked by endo- 
carditis than the left, and the murmurs which occur there must be in- 
terpreted in the same manner as in the case of the left ventricle, but, 
in this case, the stagnation of the blood in the veins of the neck is 
much more pronounced than in valvular disease of the left ventricle. 

The functional symptoms of endocarditis vary exceedingly. The 
pain is seldom regularly present, or very severe ; oppression of the 
chest, anxiety and incessant restlessness, so far as the acute rheu- 
matism will allow, are much more constant. Still, all these symptoms 
are more pronounced in pericarditis than in endocarditis. Palpitation 
of the heart is always present, and is increased on exertions, such as 
crying and bodily exercise ; and a peculiar nervous dyspnoea, or short- 
ness of breath, invariably comes on at the same time, which at first 
reveals no demonstrable mechanical causes ; later on, however, it is 
satisfactorily explained by the stagnation of the blood in the left auricle. 

Children laboring under endocarditis always have fever, and, if 
they have already got rid of the fever which accompanied the acute 
* Auriculo-ventricular opening. — Tr. 



236 DISEASES OF CHILDREN. 

rheumatism, will again be attacked by violent febrile symptoms on the 
appearance of this comjDhcation, They last for an indefinite period, 
often for many weeks ; to their intensity, and not to the commencing 
cardiac defects, is the serious emaciation of these children in greater 
part due. Furious delirium occasionally comes on, and when con- 
jointly with this the spleen is also enlarged, a condition that is very 
apt to occur in a marked degree when emboli form in it, then this 
group of symptoms may very readily be taken for that of typhus fe- 
ver. Secondary symptoms, produced by the displacement of emboli, 
are, on the whole, extremely rare in children. I have so far only once 
found embolic formations in * the spleen and kidneys ; the child was 
eight years old, and he died from endocarditis. 

The diagnosis of endocarditis is almost always attended by the 
greatest difficulties ; and this fact must especially be taken into con- 
sideration here, that not every blowing murmur of the heart indicates 
endocarditis, for children laboring under febrile diseases very often 
and very quickly get anaemic murmurs, which disappear spontaneous- 
ly as soon as convalescence commences. This is particularly observed 
in cases where abstraction of blood, even only locally, has been prac- 
tised ; and, as this remedy is often also resorted to on account of the 
rheumatic pains, anremic murmurs are therefore apt to supervene as 
the eifect of acute rheumatism. 

In addition to a blowing murmur, a more extensive impulse, an 
enlargement of the heart demonstrable by greater dulness on percus- 
sion, acceleration of the pulse, and dyspnoea, are requisite for the pur- 
pose of correctly diagnosticating an endocarditis. The terminations 
of this disease are entire recovery, complicated sequelae, or death. 
Complete recovery from a tolerably well-developed endocarditis must, 
in fact, be accounted as one of the greatest rarities, because the resi- 
due of the exudation commonly produces alterations of the valves, 
and herewith cardiac disease. Death seldom takes place at the climax 
of the disease by exhaustion or the formation of emboli ; in most in- 
stances the patients waste away under incessant fever, accidental diar- 
rhoea, or bronchitis, or perish by lobular pneumonia. The cardiac 
affections which originate from this disease often develop themselves, 
after many months, by the shrinking of the exudation, and exercise 
more and more influence upon the circulation, till finally the cardiac 
sequel, as such, makes itself manifest, and after a shorter or longer 
duration brings about a fatal end. 

(b.) Pericarditis, 

Pericarditis has been diagnosticable Avith certainty only since the 
discovery of the pericarditic friction-sound by Collin^ in 1824. But 



DISEASES OF THE ORGANS OF CIRCULATIOX. 237 

the diagnosis even at the present day is still extremely difficult and 
imperfect, as will be perceived from the following remarks : 

Pathological Anatomy. — A general and a circumscribed pericardi- 
tis, according to the extent of the affection, is spoken of. But pericar- 
ditis possesses the utmost disposition to spread, and the general is 
therefore more frequently met with than the circumscribed. The 
morbid lesion may just as readily begin on the parietal as on the vis- 
ceral coat ; and on either an injection, immediately followed by plas- 
tic exudation on the surface, takes place early in the course of the 
disease. 

Different forms of pericarditis are distinguished according to the 
nature of the exudation. 

(1.) The fibrinous exudation. In this form, the external surface of 
the heart and the pericardium are thickly coated with a shaggy, yel- 
lowish-white membrane, and are either entirely or partially united with 
each other. This exudation is capable of becoming organized, and in 
it capillary vessels soon become developed, which are often the means 
of occasioning small extravasations. Conjointly with this organized 
membrane there is always a greater or lesser quantity of fluid effu- 
sion, which, on account of the presence of dissolved shreds, and flat 
gelatinous particles of lymph, appears yellowish, turbid, and flocculent. 
Generally, this fluid portion of the exudation is subsequently ab- 
sorbed, when the firm inflammatory membranes will be everywhere in 
contact with each other, and now either become firmly and intimate- 
ly united with each other, or, when the plasticity is but shght, they 
will be ground off against each other, and almost entirely disap- 
pear. The condition denominated tendinous spots (Sehnenflecke) 
must be regarded as a residue of these processes, and the extraor- 
dinary frequency with which they are met in autopsies might readily 
convince us that partial pericarditis is often overlooked. Ossification 
of the exudation — a condition that is occasionally observed in the 
autopsies of adults — is not known, to my knowledge, in the Pasdia- 
trica. 

(2.) The purulent ichorous exudation. When the fluid effusion, 
conjoined with the fibrinous membranes, is of large quantity, and 
has a purulent consistence, the pericarditis is denominated purulent. 
No actual boundaries, however, exist between this and the preceding- 
form, for in both alike liquid and membranous effusions occur togeth- 
er. It may very readily happen that a pericarditis, which primarily 
must have been described as purulent, after a while, when the liquid 
part of the exudation has been absorbed, becomes fibrinous. In new- 
born children, on the contrary, the ichorous pyaemic pericarditis is 
almost exclusively met with. This form ^Wll be described more minutely 



238 DISEASES OF CHILDREN. 

in connection with pyoemic pleuritis. It never occurs by itself, but al- 
ways in common with pleurisy or peritonitis, and is distinguished by be- 
ing tolerably thin, of a brownish-red color and ichorous odor, and also 
by the flakes of Ijrniph suspended in it not being yello^vish-white, but 
of a grayish-brown color. Phlebites of the umbilical veins and putres- 
cence of the navel, as "will be shown further on, are generally found 
in these cases. 

(3.) The tuberculous exudation. Tuberculous pericarditis — not- 
withstanding so many children perish from tuberculosis — is a very 
rare condition. The tubercles on the pericardium are mostly larger 
than miliary tubercles in the lungs, and are sometimes found isolated, 
but sometimes again so close together that they form a rough, hilly 
membrane, the tuberculous character of which is not perceived at 
first sight. Macroscopically, however, they are easily recognized by 
the friability and the greater ease with which they are lacerated than 
the agglutinated membranes ; 'microscopically, by the tuberculous de- 
tritus. 

Symptoms. — The pathological picture of pericarditis, commonly 
delineated in the text-books, applies but imperfectly to children, for 
the phenomena are so variable that, strictly speaking, a description 
with universally adaptable symptoms must in reality be entirely 
renounced. They are often very mild, and completely masked 
by the other concomitant diseases — acute rheumatism, pyaemia, 
Bright's disease, and tuberculosis ; again, they are often very striking, 
and manifest themselves by great oppression of the chest, severe 
pain, dyspnoea, rapid pulse, fainting, delirium, and cyanosis. The 
physical examination always supplies the most important cardinal 
points. 

On inspecting the denuded chest, the heart at the commencement 
of pericarditis is seen to beat harder than usual against the expanse 
of the thoracic walls, and occasionally a slight irregularity of the 
rhythm is already observable. Later, when the exudation increases 
in amount, and particularly when the fluid part thereof greatly pre- 
ponderates, the heart becomes displaced toward the left and up- 
ward, and will beat correspondingly against the thoracic walls more 
toward the left and higher up. But if the effusion becomes still 
greater, then the most characteristic sign comes on, namely, the 
hearfs impulse can neither he seen nor felt. The pericarditic friction- 
sound, when it is heard very loudly and very distinctly, may also at 
times be discovered by palpation. 

Nothing abnormal can be detected by percussion, when the exu- 
dation is small in quantity, but, when the effusion is Hquid and of a 
large amount, a dulness over an extensive surface, having the form of a 



DISEASES OF THE ORGANS OF CIRCULATION. 239 

blunt pjTamid, the apex of -wliicli is directed upward, is obtained. 
The dulness upward, which may reach as high as the third and even 
the second costal cartilage, is especially characteristic of this condi- 
tion, and materially facilitates the diagnosis. It must not be forgot- 
ten that very decided pericarditis, in which the exudation is predomi- 
nantly of the membranous form, cannot be ascertained at all by per- 
cussion. 

By auscultation, shghtly invigorated cardiac sounds are at first 
distinguished, which occasionally only deviate slightly from the nor- 
mal rhj-thm. A friction-sound, however, soon becomes perceptible 
over one or the other portion of the dulness, which at first may 
be extremely difficult to differentiate from an endocarditic hruit ^ 
later on, however, it distinctly manifests itself as a friction-sound. 
It will resemble, according to its intensity, a slight grazing, rasp- 
ing, gnashing, or scratching, and is particularly distinguished by 
the fact that it is usually neither systolic nor dyastolic, but is heard 
between the two cardiac sounds. It is often very difficult to dif- 
ferentiate it from the endocarditic murmurs, and then it will al- 
ways be necessary to examine the patients while asleep ; and. in this 
connection it may be well to observe that the precaution should 
be taken to allow them to fall asleep in such garments as can be 
readily opened in front, and will permit the thorax to be exposed. 
The main differences are always that the pericarditic friction sound 
is limited to an extremely narrow space, and never extends as far as 
the endocarditic murmurs ; that it is neither systolic nor diastolic, 
and that it often vanishes suddenly only to reappear at an adjacent 
spot, or to remain absent permanently. In consultations this may 
sometimes be the means of causing different opinions to be enter- 
tained in regard to the disease. 

In the early stage of the disease the pulse is strong, rapid, and 
difficult to be compressed; later, it generally becomes small and 
unrhythmical, and is then easily compressed. In cases of large peri- 
carditic effusions, distinct undulating movements are observed on the 
jugular veins, and even a bulging of the veins during the systole, 
and a subsidence during the diastole takes place. At the beginning 
of the systole the tricuspid valve becomes closed, and the right auricle 
then dilates ; but, since the dilatation, on account of the existing 
effusion, cannot take place properly, a stagnation of the blood in the 
vessels consequently results, and a visible distention of the jugular 
veins is accordingly produced. Catarrh of the bronchi, and, indeed, 
also, partial compression of the right lung, are almost always asso- 
ciated with this condition. 

The functional and general disturbances are extremely variable, 



24:0 DISEASES or CHILDEEN. 

as has already been remarked at the commencement of this delinea- 
tion, and depend much more upon the complications of endocarditis 
than upon this affection per se. Its terminations are either recovery, 
of course only in rare instances, attended by a sudden disappearance 
of the friction-sound, or death, which often ensues quickly and unex- 
pectedly, or finally sequelse, such as universal adhesions of the heart 
with the pericardium, dilatations of single chambers, disease of the 
cardiac muscle proper, and, as effects of these processes, manifold dis- 
turbances of the circulation. 

Treatment. — Acute rheumatism cannot be aborted, probably not 
even shortened, in its duration; neither calomel, tartar emetic, ab- 
straction of blood, nor the cold-water treatment, produces any marked 
favorable effect upon it. Under such circumstances, we have no other 
alternative but to initiate a symptomatic treatment, in wliich morphine 
plays the greatest role, A proper dose of morphine, administered to 
the patients in some syrup, will procure them the necessary rest ; the 
process, however, is in no way modified by it. The affected joints 
should be rubbed with olive-oil, and thickly covered with cotton 
wadding, in order to protect them against all kinds of external 
violence. 

I never treat endocarditis and pericarditis, which compficate acute 
rheumatism, strictly antiphlogistically ; in well-nourished children, a 
few doses of calomel, at the utmost, may, perhaps, prove beneficial as 
an antifebrile remedy. Mild counter-irritants, such as sinapisms, dry 
cups, etc., may prove beneficial. Pyaemic pericarditis of the new-born, 
of course, always terminates fatally, and, therefore, calls for no special 
treatment. The consecutive cardiac affection requires an extremeh^ 
cautious, strict regime, as has already been more minutely pointed 
out in the preceding section, in the treatment of congenital affections 
of the heart. 

(3.) Htdeopeeicaedium — Deopst of the Peeicaedium. — Dropsy 
of the pericardium, alone by itself, occurs only in defects of the heart, 
where the disturbances of the circulation then manifest themselves 
earlier on the pericardium than on the pleura and peritonaeum. In 
most instances, however, it is complicated with serous effusions into 
the aforesaid sacs, and appears as the closing scene of dropsy, with 
usually a rapidly fatal end. In children, nephritis after scarlatina is 
almost the only cause of pure dropsies. 

Pathological Anatomy. — A light-yellow, clear effusion, varying 
from one to four ounces, is found in the pericardium, possessing the 
chemical properties of other serous effusions, i. e., that of a diluted 
serum of the blood. The pericardium, in contradistinction from puru- 
lent pericarditis, is, with the exception of a slight serous infiltration, 



DISEASES OF THE ORGANS OF CIRCULATION. 241 

perfectly intact, neither covered witli pseudo-membranes nor abnor- 
mally adherent anywhere. The muscular coat of the heart itself, as 
in all other dropsical effusions, has more of a yellowish than a red 
color. 

Sjnnptoins. — Shght pericarditic ejQFusions cannot be diagnosticated, 
and, probably, give rise to no symptoms, as the pericardium, even in 
the physiological state, contains some fluid, and the quantity of this 
fluid is subject to no inconsiderable variations. In extensive eff'usions, 
the s}miptoms of pericarditis, just sketched, will be distinctly ob- 
servable. Great oppression, and even orthopnoea, comes on ; the jugu- 
lar veins swell with every systole, and subside again with every dias- 
tole. The integument on the well-known places becomes cyanotic and 
its temperature lowered. As the pm-e hydropericardium is, in every 
instance, preceded by dropsies in other parts of the body, and v/hich, 
perhaps, still exist, its morbid picture is, therefore, materially obscured 
and obliterated ; this is especially applicable to the respiratory dis- 
turbances. The physical signs are the same as in pericarditis, only 
still more pronounced, and easier to be elicited, for these patients are 
less severely affected in their general condition, and, therefore, are 
more tranquil than those suffering from pericarditis. The prgecordial 
region bulges slightly, the impulse of the heart is weak, or entirely 
imperceptible, the pulse is small, the dulness on percussion upward 
very marked and flat. One sign only of pericarditis never occurs here, 
namely, the friction-sound, for its cause, roughened walls, plastered 
with membranous exudations, never exists here. The terminations of 
hydropericardium differ according to its cause. Those effusions which 
supervene upon diseases of the heart always terminate fatally, while 
those ensuing from scarlatina are capable of being absorbed under 
proper treatment. 

Treatment. — The diuretic treatment, as in all dropsies, is also here 
the one most indicated, and the pure roob * juniperi, without any kind 
of vehicle, is tolerated longest and best of all the diuretic remedies. 
Derivatives upon the alimentary canal should not be tried in this class 
of patients, because they always disturb the digestion, and a cure of 
dtopsy is only possible when the metamorphosis of the tissues goes on 
properly. Nor do derivatives upon the skin, by repeated vesications, 
seem appropriate, on account of the great pain they produce ; still 
less can they be used in children mth nephritis, for the cantharides 
keep the Iddneys in a constant state of irritation. Paracentesis of the 
pericardium, it is true, is recommended, in many works, for the sake 
of completeness, as a last resource, but, so far as I am aware, has 
never yet been performed in children's practice. 

* See note to page 223. — Tr. 
16 



242 DISEASES OF CHILDREN. 

B.—ABTESIES AND VEINS. 

Diseases of the arteries never occur in children, and the results of 
atheromatous affections of the arteries, which are scarcely ever missed 
in the autopsies of older individuals, are never observed in those of 
the former. The only condition of which some notice ought to be 
taken here is, an anomalous termination of the radial arteries, which, 
in some seriously sick or angemic children, may be the fault of having 
caused an unfavorable prognosis to be given. Hence, in cases of re- 
markable smallness, or complete absence of the radial pulse, it is al- 
ways necessary to ascertain the condition of other arteries, the carotids 
and temporal, before a conclusion can be formed upon the fulness or 
emptiness of the vascular system. The erectile tumors, as a stepping- 
stone in the study of the diseases of the veins, may find a place here. 

(1.) Erectile Tumoes {Noevus Vaseulosus, Arterial Teleangiec- 
tasis). — Symptoms. — By erectile tumors we understand a dilatation 
of the capillaries, a condition which occurs particularly on the face, 
eyelids, lips, and neck. This disease of the capillary vessels some- 
times affects those of the cutis, sometimes those of the subcuta- 
neous cellular tissue, and then again both, at the same time, to a 
greater or less extent. In the first case, we have a red elevation 
of the integument, of the color, and often, also, of the shape of a rasp- 
berry ; in the latter, a slightly doughy tumor, the integument cover- 
ing which is either in a perfectly normal condition, or likewise per- 
meated by dilated vessels. Generally, these vascular dilatations are 
congenital ; their growth, however, does not always progress in exact 
relation to the development of the entire organism, but surpasses it 
considerably, so that a small teleangiectasis, at birth only of the size 
of a pin's head, at the end of a year may have attained to that of a 
pea, or even of a hazel-nut. This fact is universally known ; on the 
other hand, most physicians are not sufficiently aware of the spon- 
taneous termination of these erectile tumors and vascular moles. The 
general opinion is that, if no operative assistance is rendered, they 
will continue to grow, and attain to serious dimensions, and yet the 
reason why they are so rarely met with in adults, and comparatively 
often in children, has never been satisfactorily explained. The true 
reason for this circumstance is, that most of them grow smaller spon- 
taneously, and ultimately disappear altogether, although nothing, in 
the shape of an operative procedure, had been resorted to against 
them. This spontaneous atrophy, after the manner of infantile cutane- 
ous warts, sufficiently distinguishes naevus vasculosus from mahgnant 
neoplasms. 

Erectile tumors, the integument of which is almost normal, are 



DISEASES OF THE ORGANS OF CIRCULATION. 243 

easily diagnosticated by the facts that thej disappear under the press- 
ure of the finger, become tenser and larger during crying and pressing, 
sometimes pulsate slightly, and on auscultation allow a buzzing noise 
to be heard. 

Pathological Anatomy. — When such a tumor is cut open on the 
cadaver, it collapses very much, and gives exit to a tolerable quantity 
of red serum. On closer investigation it is seen to be composed of 
merely dilated, excavated capillaries, which freely communicate with 
each other, and thus present a spongy formation. This is also the 
reason why erectile tumors are materially reduced in size by com- 
pression. If it is still further examined microscopically, there will 
be found numerous longitudinal and transverse sections of capillaries, 
and occasionally it has the appearance of small, pouch-like excavations 
in the vessels, as if the capillaries terminated with bulbous dilatation. 
Between these vessels perfectly normal connective tissue is seen. 

Treatment. — The treatment of cutaneous nasvi is different from 
that of erectile tumors of the subcutaneous cellular tissue. The 
raspberry-colored spots of the skin on the forehead, eyelids, etc., are 
best, and in the simplest manner, removed by vaccination. For this 
purpose the nsevus is punctured ten to twenty times with a needle 
dipped in vaccine matter, when a few drops of blood will always 
escape, and if nothing further is done the operation will prove entirely 
fruitless, for the vaccine lymph has oozed out with the blood. But 
if these punctures are quietly allowed to drain off the blood, then 
cleansed with a little cold water, and once more covered with a layer 
of vaccine matter, all, or nearly all of the punctures will take. On the 
fifth day the naevus displays many elevated bluish-red pustules, which 
soon become confluent, and begin to dry up by the eighth or ninth day ; 
after the crust has fallen off, a bluish-red cicatrix will at first remain be- 
hind, which subsequently fades very much.* If a child that has already 
been vaccinated comes under treatment for naevus, this procedure, of 
course, will prove entirely useless ; in such a case the neevus may be 
made to disappear entirely, or, at least, be cut up into single smaller 
ones, by producing deep, penetrating pustules, by the aid of a plaster 
composed of one part of tart, stibiat. and three of beeswax, smeared 
upon a piece of linen and worn for four or six days, at the end of 
which time small ulcers will have formed, which heal by granulation. 
The remnants of the nasvus may again be covered with the plaster 
without the least detriment. Large flat nsevi may also be made less 
noticeable by tattooing. Ten or twelve needles are thrust tln-ough a 

* Dr. Loines informs me that he has cured many na^vi by vaccination, and that 
the phenomena, in the absence of complications by violence, are almost identical 
with those of ordinary primary inf^intile vaccination. — Tr. 



2M DISEASES OF CHILDREN. 

small plate of cork-wood, and with this instrument the nsevus is punc- 
tured ail over, after which magnesia usta, or oxide of zinc, is rubbed 
in the fresh puncture-wounds. From this mixing of red and white 
a rose-color ensues, which contrasts but slightly with the normal color 
of the surrounding integument. 

It is always well to bear in mind, before any intense cauterizations 
are resorted to with Vienna paste, chloride of zinc, sulphuric acid, etc. 
— from which large gangrenous ulcerations and disfiguring cicatrices 
sometimes ensue — that many nosvi in time disappear spontaneously, 
and at the utmost leave behind them a slightly redder-colored spot on 
the skin, which certainly disfigures less than the large, radiating, con- 
tracted eschars that result from the operations. I have established it 
as a rule for myself, not to treat surgically any cutaneous neevi which 
cannot easily be surrounded by two curved incisions, and the lips of 
the wound accurately united through the bloody suture. 

The case is totally different with the subcutaneous erectile tumors, 
which, on the whole, are far more infrequent than teleangiectasis 
of the cutis. Through spontaneous rupture or slight injuries they 
may give rise to serious hsemorrhages that may endanger life, and 
their treatment should not be deferred on that account alone. In 
some instances it has, indeed, been possible by steady compression to 
cause such tumors to disappear, but for this method a great deal of 
time and patience is necessary, and, in addition, the presence of a 
firm, bony substratum; otherwise the attempt at compression w^ill 
prove entirely fruitless. Formerly the ligature was principally em- 
ployed in the removal of these subcutaneous capillary extuberations ; 
a needle armed with a double ligature, or, still better, a narrow tape, 
was drawn through the base of the tumor, then tied in two sections 
at opposite points, and allowed to ulcerate its way through ; of late, 
the galvano-caustic has rendered essential service in these cases. 
For this purpose several platinum w^res are introduced into tlie base 
of the tumor in opposite directions, at a distance of two or three lines 
from each other, and brought to a white heat by the aid of the bat- 
tery, by which coagulation of the blood, suppuration, ulceration, and 
finally healing, are achieved. 

(2.) Theoivibi in the Sinuses oe the Duea Matee. — Many in- 
vestigations have been made in this direction since the time Virchow 
developed and cultivated the study of the formation of thrombi, and 
the pathological condition in its signification upon the course of the 
disease has come to be more appreciated. Thus, Gerhard found 
thrombi in the sinuses of the brain seven times in the autopsies of 
ninety-six children, and all of those seven children died from profuse 
diarrhoea, attended by cyanosis, coma, and com^sions. 



DISEASES OF THE RESPIRATORY ORGANS. 245 

But there is the greatest difficulty in determining the ages of these 
thrombi. Whether a thrombus has formed before death, in the 
mortal agonies, or only after death, cannot always be decided. The 
cardinal points which mil lead us to settle this question correctly are, 
the aiTangement of the layers of the thrombi, their central softening, 
and their adhesion to the walls of the veins ; whether they are of a 
yellow or red color is a matter of no such great importance. It seems, 
however, that they are not pathognomonic of the atrophy of children, 
for I have often missed them, and in other cases found red, fresh 
thrombi, which undoubtedly only originated after death. This con- 
dition, therefore, has but slight clinical importance. 



CHAPTER IV. 

DISEASES OF THE RESPIRATORY ORGANS. 

A.— NASAL CAVITIES. , 

As the diseases of the mouth have already been spoken of in con- 
nection with those of the digestive apparatus, there remain only for 
consideration those of the nares. The method of examining the nares 
is a simple one, and offers but few difficulties, since it is limited en- 
tirely to an inspection or exploration, by the aid of a probe or catheter. 
Wintrich has found that the permeability of the nasal passages may 
be confirmed by percussing the larynx. "When, the mouth being closed, 
percussion is performed over the larynx, the tympanitic percussion- 
sound that is produced by it becomes dull if one of the nasal open- 
ings is closed, and still more decidedly flat when both nares are com- 
pressed. Now, if, by the closing and reopening one or both nares, the 
tympanitic sound does not change in intensity, it may be regarded as 
proof that the affected nostril is occluded at some point higher up. 
But this method of examination can only be exercised in old chil- 
dren — those that will close the mouth when ordered to do so, and who 
willingly allow the nares to be compressed, and the larynx to be per- 
cussed. Such children will also snuffle in and out when so ordered, 
and the permeability of the nasal passages may in this manner be 
ascertained more conveniently than by percussing the larynx. 

(1.) Epistaxis — Bleeding of the Nose. — Epistaxis, as, in fact, 
all hemorrhages, is produced by a rupture of vessels ; in this case, of 
the capillaries of the mucous membrane of the nose. 

Etiology. — The causes are divisible into local and general. The 
local are injuries of all kinds, blows, contusions, lacerations, etc. Still, 



246 DISEASES OF CHILDREN. 

even here, the individual disposition is not to be lost sight of, for the 
various injuries produce entirely different effects, according to the ex- 
isting disposition to bleed from the nose. A local causation is also 
found in the various forms of ulcerations of the mucous membrane. 
To the general causes, all conditions which are combined with stasis 
of the venous circulation belong, such as cardiac malformations, goitre, 
the so-called general plethora, pneumonia, and typhus fever, and par- 
ticularly the diseases in which actual disturbances of the capillary 
system of vessels are superinduced, such as scorbutus and morbus 
maculosus, and diseases of the blood like chlorosis. Finally, vicarious 
haemorrhages occur in girls at the time when menstruation should take 
place. 

Symptoms. — The blood either makes its appearance in drops, as 
stilhcidium sanguinis — the ordinary form — or it flows in a continuous 
stream, rhinorrhagia, a rare and exceptional form. As regards the 
quantity of blood lost, we are often unintentionally deceived by the 
relatives, for they forget that the child has bled into a vessel contain- 
ing water, and, when they behold the dark red-colored water, im- 
agine it to be all blo'od. Once, in a case of a boy nine years of age, 
who was reported to me as having daily lost " enormous quantities " 
of blood, I collected what flowed from his nose during thirty-five 
minutes (after which time the haemorrhage ceased spontaneously), not 
quite one ounce of blood, a quantity that certainly ought to cause no 
great anxiety. 

Children under three or four years very rarely suffer from epis- 
taxis from general causes, but only in consequence of injuries or ul- 
cerations, in which the haemorrhage is never profuse. In older chil- 
dren all the above-mentioned causes are to be taken into consideration. 
In children laboring under febrile diseases, it occasionally happens 
that the blood flows backward into the pharynx and is swallowed, 
when hgematemesis may occur, or black, and more or less bloody 
stools be voided. Usually, the bleeding does not last an hour ; in 
exceptional cases, however, it may be protracted for half a day. 

Its pathological signification is naturally very different, according 
to its severity and etiology. Epistaxis is to be regarded as a favora- 
ble phenomenon in all febrile affections, in venous congestion, and in 
expected menstruation ; as unfavorable, and tending to aggravate the 
condition, in scorbutus and chlorosis. 

Treatment. — From the preceding explanation, it follows that the 
treatment must be exceedingly variable. In scorbutus and chlorosis 
it must be arrested promptly. When occurring in the other states we 
have mentioned, the measures to be adopted will depend upon the 
profuseness of the flow, the frequency of the recurrence of the bleed- 



DISEASES OF THE RESPIRATOKY ORGANS. ' 247 

ing, and the more or less anfemic appearance of the child. The best 
method of arresting the haemorrhage is to introduce a few bits of ice, 
of the size of a pea, into the nares, and then to plug these up with a 
good-sized charpie tampon. The tamponing of the posterior nares 
through the mouth, by the aid of Bellocque's tube, is very annoying 
to childi^en, and should only be resorted to in extreme cases of scor- 
butus or chlorosis. Where no ice is to be had, it is very advantageous 
to dip the tampon in liq. ferri sesqidchlor. The deligation of the 
upper and lower extremities, and the keeping of the arms elevated 
above the head, are popular old remedies. 

That the primary causes always deserve a special consideration is, 
of itself, understood. In order to avoid repetitions, the student is 
referred, concerning their treatment, to their respective sections. 

(2.) CoKYZA — Rhi]STTIS — Catakeh. — By coryza a catarrh of the 
mucous membranes, of one or both nares, is understood, in which af- 
fection the mucous membrane always appears reddened and swollen. 

Symptoms. — The secretion poured out by the mucous membrane at 
first is clear and liquid, but after a few days becomes glairy and 
opaque, until it finally again assumes the properties of the normal 
nasal mucus. Its reaction is always decidedly alkaline, and the 
amount of soda it contains may increase so much as to produce a 
slight corrosive efi"ect upon the upper lip and alee nasi. These local 
signs, reddening and erosions, and the inflammation, are intensely 
aggravated by the constant wiping, which the nursery-maid does not 
always perform in the most tender manner. So long as the catarrh is 
limited to the nasal mucous membrane, it is generally unattended with 
fever, but when it implicates the frontal sinus, or the supramaxillary 
cavities, conditions which can only be ascertained in older children by 
inquiries, it becomes febrile, and is accompanied by severe pains in 
these cavities. When the catarrhal inflammation of the Schneiderian 
membrane extends to the conjunctiva, through the lachrymal canals, 
redness, pain, intolerance of light, in short, conjunctivitis catarrhalis, 
become superadded, and, when finally it passes along through the 
Eustachian tubes into the tympanum, tinnitus aurium, otitis, and 
dyscophosis, come on. In other cases, the catarrhal inflammation 
travels downward into the larynx, causing hoarseness and pain, and 
from thence into the bronchi, where it terminates in bronchitis capil- 
laris in the pulmonary alveoli ; or, lastly, the stomach and intestinal 
canal become involved, when loss of appetite and vomiting of large 
quantities of mucus, or slimy diarrhoea, will be superinduced. 

In older children, these conditions, even when all the enumerated 
complications become superadded, are always devoid of danger ; but, 
in the new-born child and nursling, a complete occlusion of the still- 



248 DISEASES OF CHILDEEX. 

narrow nares, by the tumefaction of tlie mucous membrane and the 
accumulation of the secretion, rapidly ensues. The usually closed 
mouth must now be constantly open, its cavity becomes dry, and the 
breathing loud and rattling. And if these children now attempt to 
nurse, or take the bottle, they experience great difficulty in breath- 
ing, and are obliged to forsake the breast and food, hence their nu- 
trition rapidly suffers, and emaciation supervenes. 

Occlusion of the choanee by thrush-spores also occurs in young 
children who suffer from thrush of the mouth, causing severe 
dyspnoea. 

Side by side with catarrhal coryza, various cachexise manifest 
themselves in the nasal passages. Thus there is a chronic, scrofulous, 
syphihtic coryza, and, in very rare instances, a coryza produced by a 
contagious mucous discharge, in which the secretion is of a totally 
different nature from simple catarrh ; sometimes, even some of the 
bones are destroyed by necrosis. More will be said about this con- 
dition in connection with the respective dyscrasise. 

Etiology. — Simple nasal catarrh occurs in a sporadic and epidemic 
form; the epidemic occurrence is induced by undue quantities of 
ozone in the air, or by mechanical and chemical adulterations of the 
same ; for example, by dust, in the firing up of a stove unused for 
some time, etc. The hability also to become infectious, by a contami- 
nated breath, is not to be ignored. The sporadic and very chronic 
cases, as a rule, are of a cachectic nature. 

Treatment. — ^In the ordinary catarrhal form, there is no urgent 
indication for interference ; still it is well to take the precaution to 
keep the children in a uniform temperature, and to avoid sudden and 
extreme cooHng of the skin, cold affusions, and cold baths. The 
various abortive treatments that have been tried of late, by injections 
of solutions of zinc, alum, and morphia, in young children who are un- 
able to blow them out again, and otherwise liable to swallow them, 
are altogether inadmissible. The nostrils of nurslings, thus occluded 
by swelling and secretion, must be made permeable by the use 
of olive-oil, introduced by a small brush at least one inch, and re- 
peated three or four times daily ; this procedure will be all the 
more successful if they sneeze each time, and thus expel the hardened 
mucous crusts. The cachectic coryza of course does not yield to a local 
treatment, but must be removed by internal antidyscrasiac remedies. 
Cod-liver oil is the most effective remedy for the scrofulous form, and 
a mercurial treatment will be required for the syphilitic. 

(3.) Adventitious Geowths in the Nose. — Polypi are the only 
morbid growths ; they only occur in older children ; and with them 
they are much rarer than in adults. The youngest child in whom I 



DISEASES OF THE EESPIRATORY ORGANS. 2i9 

twisted off a fibrous polypus was four years old. By polypi we under- 
stand two kinds of tumors, wliicli differ considerably from each other. 
Soft polypi are cystic gelatinous excrescences upon the mucous mem- 
brane ; they usually spring from the outer wall of the nares, and, on ac- 
count of their softness, are called cystic or mucous polypi. The hard 
polypi do not spring from the mucous membrane, but from the submu- 
cous tissue, or from the perichondrium. They consist of connective 
tissue, are of a rosy-red color, and, on account of their hardness, have . 
been called fibrous or sarcomatous polypi. Both kinds are pediculated, 
and enlarge themselves into oblong tumors, corresponding to the shape 
of the nares. The fibrous polypi may attain to so co^isiderable a size, 
especially backward, as to hang down into the pharynx, and embar- 
rass deglutition and even respiration. 

Etiology. — According to the text-books, polypi originate from 
chronic catarrh. This theory rests upon a feeble foundation, and has 
many exceptions. Their rare occurrence in children also speaks 
against it, for in these especially the mucous secretion is much 
greater, even in the physiological state, than in adults. In the few 
instances that I have had the opportunity of observing in children, no 
chronic catarrh preceded them, and no peculiar etiological reason 
whatever could be discovered. 

Symptoms. — So long as the polypi are small, ahd the nares not 
blocked up, they seem to give rise to but few, or no embarrass- 
ments. But when impermeabihty of the nasal passages has been pro- 
duced, then the patients lose the sense of smell, the voice becomes 
snuffing, the mouth is constantly kept open, giving them a silly ap- 
pearance, and they are continually but uselessly seeking to free the 
nasal passage by blowing the nose. Now and then one of these 
cystic polypi, through the violent snuffing and pressure, will burst, 
the contents be discharged, and the air once more pass freely 
through the nares. But, as . cystic polypi usually exist in numbers, 
the smaller ones rapidly follow in growth, occlude the passage anew, 
and the old condition is reproduced. Firm sarcomatous polypi are 
also capable of blocking up the lachrymal canal, and the Eustachian 
tube, and thus produce stillicidium lachrymarum and hardness of hear- 
ing. In cystic polypi this is not observed. In both forms, a mucous 
or purulent coryza, and even ulceration of the mucous membrane, may 
take place, as a result of which small hasmorrhages also occur. The 
diagnosis is very easy ; ordinarily the polypi reach the margin of the 
nares, or even protrude. When this is not the case, the impermea- 
bility of the cavity in question may be readily ascertained by com- 
pressing the opposite one, and causing the patient to blow his nose. 
From the presence of foreign substances, polypi are distinguished by 



250 ' DISEASES OF CHILDREX. 

the slowness of their growth, by slight painfulness, and their chronic 
course. Cystic poljqDi very frequently return ; fibrous polypi, when 
thoroughly removed, generally do not. 

Treatment. — Internal remedies, as well as the local application of 
astringents, have proved to be totally useless ; the only eflPectual treat- 
ment consists in twisting off and eradicating the polypus, care being- 
taken to grasp it close to its origin, from the mucous micmbrane. 
A long, slender, serrated forceps is the best instrument for this pur- 
pose. 

For the removal of fibrous pol_ypi "with broad pedicles, Middel- 
dorpf^s galvano-caustic is very well adapted. The hgemorrhage pro- 
duced by the evulsion of the polypus is readily arrested by injections of 
cold water, and the introducing of pieces of ice. After the removal of 
cystic polypi, dossils of charpie, smeared with red-precipitate ointment, 
should be introduced into the nares for several weeks, to prevent its 
return. 

(4.) FoEEiGX Bodies in the Nose. — Children from two to eight 
years of age very frequently introduce extraneous substances into 
the nose. The most common are cherry-pits, small round pebbles,- 
glass beads, peas, beans, and paper balls. In addition, insects, such 
as flies and bugs, gain an entrance into the nose while children are 
asleep, or a round-worm strays (probably during a fit of vomiting) 
into the nose. Generally, as soon as a child introduces a foreign 
body into the nose, it straightway tries to remove it by boring 
with the finger, and thereby only pushes it into the choanae, where it 
finally becomes lodged. The irritation that is produced by these foreign 
bodies varies according to their composition. If some part of the 
surface is rough, painful swelling and coryza will soon be induced ; 
beans and peas produce the greatest amount of irritation, they soon 
swell up in the moist warm cavity, and may even begin to sprout there. 
A remarkable case of this kind is recorded by Soyer, in which a pea 
germinated in the nose of a child and bore ten or twelve roots, one of 
which grew to three and a quarter inches in length. 

The nose becomes very painful, and, without chloroform, no thorough 
examination can be made. The termination is most favorable in those 
instances where paper balls have been introduced into the nose ; they 
soon soften and are discharged piecemeal. However, cases are also 
said to have occurred in which the foreign bodies produced severe irri- 
tation, delirium, meningitis, and death. The condition called rhino- 
htes, in which successive deposits of inorganic salts take place around 
the foreign body, sometimes met with in the adult, is, so far as I know, 
unknown in the Psediatrica. 

Treatment. — A painless and yet in many instances a successful 



DISEASES OF THE RESPIRATORY ORGANS. 251 

remedy is, the act of sneezing, which may be excited by a pinch of 
snuflP, used in the sound nostril. Even when the extraneous body is 
not entkely expelled, it will nevertheless always be found to have 
been propelled forward, and somewhat loosened. As soon as it be- 
comes visible, it may be extracted with a very fine dentated forceps or 
DavieVs scoop. Soft bodies may also be crushed with a strong den- 
tated forceps, when the single pieces will soon be expelled. The 
attempts at extraction should never be persevered in too long, because 
very severe swelling of the mucous membrane will thereby be pro- 
duced. They may be repeated again in a few days. Under no circum- 
stances is the nose to be split open hastily, as recommended by Dif- 
fenhach / the operation should be deferred until critical cerebral symp- 
toms render it necessary, which, on the whole, very rarely occurs. 

^.—LABYNX AND TRACHEA. 

(1.) Ceotjp (Laryngitis and Tracheitis 3£aligna). — It is not 
easy to find, for one and the same disease, so many and different appel- 
lations as for croup. The most current are : CynancJie trachealis ; 
angina laryngea exudatoria^ sive polyposa, sive memhrajiacea, sive 
strepitosa-perfida-mortalis ; laryngea tracheitis exudativa^pharyngo- 
laryngitis pseudomembranacea / morbus strangulatorius / suffocatio 
stridida ; membranous quinsy. The shortest of all of these titles, 
croup, has received the preference, and in the Scotch vernacular prop- 
erly expresses a white membrane found upon the tip of the tongue of 
sick chickens, in the disease called " pip." 

In ancient times croup seems to have occurred very rarely ; for not 
even one characteristic description can be found in the writings of the 
old physicians, whose accurate powers of observation no one will pre- 
sume to question. Baillou^ in 1576, according to Fredrich, is the 
first who mentions having undertaken a dissection of croup. The lit- 
erature of croup received a great accession through the proclaimed 
concours of Napoleon I., occasioned by the rapid death of his nephew, 
the son of the then King of Holland, who fell a victim to this disease 
in 1807. Eighty-three dissertations on croup were sent in. Jurine^ of 
Genf, and Albers, of Bremen, received prizes, and many others were 
honorably mentioned ; none, however, knew of any remedy by which 
the mortality of the disease could in any way be ameliorated. As 
Napoleon was chiefly concerned about the latter, and not in the en- 
riching of the symptomatology or the pathological anatomy of croup, 
the writings of the entire concours must therefore be regarded as hav- 
ing disappointed him. 

Pathological Anatomy. — Croup consists of a certain group of symp- 
toms, which in different individuals always manifest themselves in the 



252 DISEASES OF CHILDREN. 

same manner. We do not intend to be understood as saying that these 
sjTiiptoms are always indicative of the same anatomo-jDathological altera- 
tions ; on the contrary, there is abundant evidence that it may depend 
upon three different kinds of processes upon the mucous membrane of 
the larynx. The exudation poured out by the inflamed mucous mem- 
brane may be either («) muco-purulent, or (5) simply fibrinous, or (c) 
diphtheritic. 

(ad a.) The laryngeal mucous membrane, which, during life, is 
probably intensely red and strongly injected, does not generally re- 
tain that color after death, but is only slightly reddened ; its inflam- 
matory swelling, however, continues, and may be readily demon- 
strated by a perpendicular incision. This inflammatory thickening 
is also found in the glottis. The entire larynx and trachea are lined 
by a tenacious, yellowish mucus, which is with difiiculty wiped away. 
In some places the inflamed mucous membrane displays small catar- 
rhal abrasions, and its follicles are enlarged, so that, when the mu- 
cous membrane is rendered tense by bending or twisting the trachea, 
a minute bead-like drop of grayish-white mucus will rise out from 
every crypt. This muco-purulent exhalation may extend down into 
the very smallest bronchi. 

(ad J.) With the condition just described, which, in fact, must 
necessarily be found in every dissection of croup, a fibrinous exuda- 
tion of more or less thickness usually becomes associated, and may 
be readily peeled off from the inflamed mucous membrane without 
causing any actual loss of its substance. Microscopically these mem- 
branes consist of band-like fibrinous cords, between which numerous 
pus-cells are deposited. The latter did not originate in. the fibrine, 
but were already previously present upon the mucous membrane, and 
subsequently became surrounded by the fibrinous exudation, and 
locked in by the coagulation that ensued. The membranes vary very 
much in extent. Sometimes very thin, cobweb-like, small patches 
are found at one or several places of the larynx ; in other cases the 
membranes are of the thickness of the back of a knife, yellowish- 
white in color, covered on their upper surface by a cream-like coating-, 
and line the entire larynx, trachea, and the bronchi of the higher 
order, so completely that they appear like a prepared connective, 
dentritic tubular system, and may be pulled out entire. The tonsils 
and pharynx are also occasionally seen to be coated with these mem- 
branes. 

(ad c.) In diphtheritic larjrngitis a grayish-white exudation into, 
not upon^ some portions of the mucous membrane is poured out. 



DISEASES OF THE RESPIRATORY ORGANS. 253 

This grayish mass of exudation, beneath which the mucous mem- 
brane, as well as the epithelium, is soon destroyed, consists of an 
amorphous detritus, in which no hands of fihrine and but few pus- 
cells are found. It is not as easily pulled off from the mucous mem- 
brane as the simple fibrinous membrane, and generally covers also 
the palate, tonsils, and pharjnix. The distinction between purely 
fibrinous and diphtheritic croup is entirely a microscopical one. 

A^Tien the diphtheritic layer becomes detached during life, an 
ulcer remains behind, the margins and base of which soon become 
coated with a new grayish deposit. Diphtheria, according to 
'Virchow's views, is to be regarded as a progressive inflammation, 
with partial destruction and sloughing, of the mucous membrane. 
Diphtheritic laryngitis occurs in an epidemic form, and frequently 
follows upon morbilli and scarlatina. 

The pulmonary parenchyma is found altered in all the three forms. 
Usually the lungs do not collapse on opening the thorax, because the 
air in the bronchi is prevented from escaping by the mouth, by the 
large quantities of bronchial secretion; often diffused pulmonary 
oedema and very generally lobular, sometimes also lobar pneumonia 
or tuberculosis, are present. 

The adjacent lymphatic glands of the neck and nape, as well as 
the bronchial glands, are often swollen and hyperaemic. 

The rest of the organs, with the exception of venous stasis, ex- 
hibit no characteristic morbid changes. 

Symptoms. — The prodromata of croup are seldom particularly 
significant. The children have a cough, sneeze, and suffer loss of 
appetite for a few days, and sometimes are less lively than usual ; 
still, it also happens that they retire to rest perfectly well and serene, 
and, after sleeping the first hours of the night, suddenly wake up 
with a croupy cough, upon which the symptoms may develop them- 
selves so rapidly that the physician who is called in on the following 
morning finds a complete, well-marked croup. This first stage, the 
stadium prodromorum, is not noticeable, simply for the reason that, 
in many cases, it does not occur at all, and, in still more, offers no 
pathognomonic symptoms whatever. 

The commencement of croup is, with justice, dated from the mo- 
ment in which the first morbid change in the larynx manifests itself 
through the voice and cough. The voice becomes hoarse and husky, con- 
stantly lower and lower, till it finally disappears so completely that 
their efforts to speak can only be heard in their immediate vicinity. 



254 DISEASES OF CHILDREN. 

Even tlie most intense pain or anger does not enable the child to utter 
a loud sound. As soon as the voice becomes hoarse and rough, a res- 
piration, audible throughout the room, supervenes. The sounds ac- 
companying the breathing are best imitated by pointing the lips as 
if about to whistle, but, instead of whistling, you merely inspire and 
expire through the sharply-pointed lips. A sound is thus pro- 
duced which is midway between an active breath and a whistle. In 
croup it approximates more to the active breathing than the whistling 
tone. The inspirations constantly grow more frequent, and finally 
the number of respirations may rise to sixty and more in the minute. 
They also become irregular, sometimes deep, sometimes superficial, 
and the accessory muscles of the respiratory muscular apparatus par- 
ticipate more and more in every act of respiration. 

Simultaneously with the hoarseness and the loud breathing, a 
cough supervenes, the tone of which is so characteristic that, for 
brevity, it has been called " croup cough." It is a barking, toneless, 
dry cough, and has been compared, not inappropriately, to the first 
attempt at crowing of a young rooster. At first it is tolerably ab- 
rupt, and terminates with a single expiration ; soon, however, it be- 
comes a regular paroxysm of cough, which may last one and subse- 
quently several minutes. In the first day of croup these severe 
cough paroxysms are rare, and recur only every four or six hours. 
Soon, however, they become aggravated in intensity, as well as in 
frequency, and are quickly induced by the least external irritation, by 
drink, or pressure on the tongue, for the purpose of examining the 
throat, etc. They abate, and even disappear altogether, at the ap- 
proach of death. In consequence of this cough, children become 
livid in the face, the eyes protrude, staring and congested, from the 
sockets, the veins of the neck and head swell up into thick tense 
cords, the forehead becomes covered with perspiration, but the cough, 
notwithstanding the most violent exertions, remains totally aphonic, 
accompanied by the expectoration of only small quantities of frothy 
mucus. These paroxysms of cough are distinguished from those of 
whooping-cough, which are also interrupted by a whistling inspiration, 
by their sufi'ocative character, aphonic tone, by the absence of expec- 
torations, and vomiting. Moreover, in pertussis, the child is well 
immediately after the termination of the paroxysm, and the voice 
is natural, while croup patients are seriously sick, and the voice is as 
much aphonic afterward as before. 

It is a mistake to ascribe the croupy cough and the loud breathing 
to true croup only, and to consider all the larj^ngeal aiFections in which 
this cough is heard as genuine croup. To this error, no doubt, a great 



DISEASES OF THE RESPIRATORY ORGANS. 255 

many of the recoveries from attacks of croup, in which a few leeches 
or some other therapeutic procedure rendered such "excellent ser- 
vice," are due. Very simple, mild cases of laryngitis often occur in 
which children have no fever at all, and retain their appetite, but 
which nevertheless are accompanied by the same hoarseness, the same 
tone of the cough, and the same loud respirations, for many days to- 
gether. This condition may even become chronic, may be produced 
by hypertrophied glands growing around the trachea, and last for 
many years. 

In genuine croup, an increased temperature of the skin is present 
from the very first, by which, in fact, the general disease manifests it- 
self. The acceleration of the pulse is, in this disease, as in most in- 
fantile diseases, of little significance, since even a trifling catarrh will 
produce it. Croupy cough, hoarseness, and loud respirations, do not 
suffice for a diagnosis of croup; the symptom of continuous fever must 
be present. This consists, above all, in a marked, perceptibly-in- 
creased temperature of the skin, in loss of appetite, in augmented 
thirst, and in acceleration of the pulse. 

Concerning the appearances of the mouth, authors of various coun- 
tries differ according to the countries in which they have carried out 
their investigations. In France, particularly in Paris, where the diph- 
theritic croup seems to occur almost exclusively, it is a rare exception 
to find a cliild with croup who has not its posterior pharyngeal wall, 
tonsils, and palate, of a dark-red color, covered with tenacious mucus, 
and even w^ith dijDhtheritic exudation. In the many patients with 
this disease whom I have had to treat in Munich, I have hardly seen 
a membrane, rarely any thick mucous coating, and only a moderate de- 
gree of redness of the posterior parts of the mouth. The case is dif- 
ferent again in middle and north Germany, where membranes are 
often found upon the tonsils, and severer pharyngitis is observed, 
while English authors consider croupous angina as an exceptional oc- 
currence. The reason for these diverse statements is found in the 
diversity of the anatomo-pathological process. In the one case, croup 
is produced simply by a plastic exudation within the larynx, which 
does not generally extend above the epiglottis ; in the other by diph- 
theritis, which almost always occurs simultaneously upon the tonsils. 

Auscultation of the lungs always reveals widely-diffused sonorous 
rales, but the whistling laryngeal breathing is so intense that it com- 
pletely obscures the vesicular breathing. If the croup has existed for 
one or two days, circumscribed or more extensive dulness and bron- 
chial breathing, especially over the back, will also be found, due to 
lobular or lobar pneumonia. In rachitic children, acquired atelec- 
tasis and rachitic carnification of the lungs rapidly increase in cireum- 



256 DISEASES OF CHILDKEN. 

ference, and become surrounded bj pneumonic infiltration. The expec- 
toration, as has been already stated, is mostly slight, a frothy white 
mucus, but occasionally croupous membranes are coughed up during 
the paroxysms, representing sometimes single patches with fringed 
borders, sometimes entire closed tubes of greater or less calibre, ac- 
cording to size of the air-tube from which they have been detached. 
"With the expulsion of such membranes, little or but a temporary 
amelioration takes place, and the prognosis consequently does not 
improve in the least. This is now a well-established fact, and yet 
physicians do not cease to torture the poor croupy children with emet- 
ics, and triumphantly pull out a membranous piece from the vomited 
matter, and, when death ensues notwithstanding, as it usually does, 
" the doctor is supposed, at any rate, to have done his duty." 

Slight compression of the larynx generally causes severe pain, 
while deglutition is only embarrassed and painful when the tonsils and 
fauces are also implicated, a condition usually not present in this 
country. The bowels are generally constipated, and the urine is nor- 
mal, or shghtly reduced in quantity. 

If the symptoms hitherto depicted have lasted for one, or at 
the most two days, the effects of embarrassed respiration supervene. 
The lips, cheeks, and tips of the fingers, become cyanotic, the dyspnoea 
intense, the child sits upright in bed as long as its strength will allow, 
and keeps the head extended backward. All the accessory respiratory 
muscles are in a state of the utmost activity, so that the head, with 
every ins]3iration, is made to approximate the chest. With the des- 
peration of deathly fear they tear the clothes from the breast, and 
puU at the neck as if they would try to remove the cause of their 
dyspnoea. The httle hands, with cramp-like tenacity, grasj) at the 
sides of the cradle, or some other firm object near them, so that the 
pectoral muscles may the better serve as respiratory muscles. They 
never remain long in one posture, and, by constantly changing their 
position, seek to obtain an endurable attitude. The pulse becomes 
almost uncountable, unrhythmical, and uneven. Several hours before 
death a remission of all the symptoms usually takes place, the dysp- 
noea diminishes, yet the respiration remains accelerated, the child 
again hes down upon the pillov/, its expression of extreme anxiety has 
disappeared, and that of indifference or of unconsciousness has taken 
its place. The inexperienced parents usually regard this condition as a 
commencing improvement, but to the physician the clammy cold 
sweat, the increasing cyanosis, the unequal, uncountable pulse, prog- 
nosticate a speedy end. 

As regards the explanation of the dyspnoea, and of the paroxysms 
of cough, it is usually assumed that the former is produced by the 



DISEASES OF THE RESPIRATORY ORGANS. 257 

croupy membranes, the latter by a spasm of tlie glottis. But against 
these suppositions -weighty objections appear. The diligent physi- 
cian, who does not omit to examine every child that dies from croup, 
knows that the thickness and extent of the croupous membranes do 
not stand in exact relation to the symptoms observed during life. 
Where, on account of the most violent dyspnoea, abundant membra- 
nous formations are expected, only a few, circumscribed, gauze-thin 
patches are present ; and, conversely, where the croup produced less 
horrible s;yTnptoms, the whole larynx, the entire trachea, and even the 
bronchi, on dissection, are often seen to be lined with tubular mem- 
branes, of the thickness of the back of a knife. Consequently, it seems 
to depend more upon the degree of the oedematous swelling, which 
implicates the mucous membrane of the glottis, than upon the mem- 
branous formations. The oedema of the glottis, however, almost 
always escapes the notice of the pathological anatomist, on account of 
the change of its form that has taken place. 

Schlautmann offers valid objections against the theory of spasm. 
He contends that, in such a kind of inflammation of the mucous mem- 
brane, a paralysis of the subjacent muscles takes place as a result of 
the oedema, and compares croup with the symptoms observed in ani- 
mals after division of the pneumogastric nerve. When this operation 
is performed, it also causes the most violent dyspnoea, implicating all 
the auxiliary respiratory muscles ; there is prolonged inspiration, accom- 
panied by a noise, and short expirations. The deep, rough, hoarse 
tone of the voice, as well as the cough, much more probably indicates 
paralysis than spasm of the glottis. In the latter condition, the chords 
vocales are in a state of extreme tension, and, consequently, give high 
tones, not deep, rough ones. Again, in every inspiration, the chink 
of the glottis is dilated by muscular contraction, but, when this is abol- 
ished, it will flap hither and thither, like a loose sail, and exposure of 
the glottis, after division of the N. vagi, has demonstrated that the 
paralyzed glottis contracts in every inspiration, particularly when the 
act is a forced one. Thus the dyspnoea is greater in animals with 
paralysis of the laryngeal muscles when the animal is stimulated to 
deep inspirations. The case is similar in children affected with croup. 
So long as the child can breathe calmly, it is not much annoyed, but, 
during coughing, crying, and on waking from sleep, when deep inspi- 
rations always take place, the paralyzed glottis becomes closed, and 
the S3rmptoms of the most violent dyspnoea are induced. Thus, then, 
the older view of spasm of the glottis is tolerably well refuted by this 
{Schlautmann^ s) statement, and must give place to paralysis, unless 
further physiological experiments sliould give this discovery a new 
signification. 

* 17 



258 DISEASES OF CHILDREN. 

Striking as the symptoms of croup are, still, the diagnosis is by no 
means easy, and, in this disease more than in any other, both inten- 
tional and unintentional errors occur. For the purpose of confirming 
the diagnosis of true croup, it is requisite that (1) the symptoms of 
continuous fever, hot, dry skin, rapid pulse, loss of appetite, and men- 
tal depression, be present ; (2) croup cough, (3) hoarseness, (4) loud, 
croupy breathing; and (5) suffocative attacks. In this condition, the 
posterior parts of the mouth need not necessarily be altered, but in 
diphtheritis they are generally covered with a white, island-like exuda- 
tion. If any one of the symptoms just enumerated is absent, particu- 
larly when the fever is not decidedly pronounced, then we have no 
cronp before us, but a simple catarrhal laryngitis, without any danger- 
ous SAvelling of the mucous membrane, a condition that has been called 
pseudo-croup^ which, it is true, after several days, may run into the 
most complete genuine croup, and terminate in death. This is most 
probably the form in which, at the autopsy, no membranes, but thick, 
tenacious mucus, and redness and swelling of the laryngeal mucous 
membrane, are found ; the symptoms during life, however, were not 
less violent than in the membranous form. 

From the lack of harmony between the symptoms and the antomo- 
pathological process, it seems to me that it may be justly concluded 
that croup is no local laryngeal affection, but a general disease, a tox- 
aemia, perhaps, with localization upon the larynx, and that the lar^na- 
geal phenomena may stand in about the same relation to the whole 
disease as the tj^hous ulcerations to abdominal typhus. A fmi;her 
proof that diphtheria, at least, is no local affection, is derived from the 
formations of membranes upon a blistered wound on the sternum, 
for example, when a blister is applied, according to iMZsinsJcy^s 
method, u23on such a croupy child. The raw surface will become cov- 
ered, once or twice daily, with false membrane, which has the greatest 
resemblance to those diphtheritic depositions upon the larjnigeal mu- 
cous membrane. And only in this manner is it possible to explain why 
early and skilfully-performed tracheotomy can be so uniformly fruitless, 
for the trifling effects of this operative procedure, when practised in 
other laryngeal affections, cannot possibly be the cause of its total 
uselessness in crou2D. 

Occurrence and Course. — Tlie diphtheritic croup, which comes on 
particularly after scarlatina, is markedly contagious, and very frequently 
attacks several children of one family one after the other. In that 
form characterized by simple fibrinous depositions this contagiousness 
is not observed. The latter form occurs most frequently during the 
prevalence of cold, sharp north and east winds. I have, however, seen 
it at all times of the year, and under all conditions of the weather. 



DISEASES OF THE RESPIRATORY ORGAXS. 259 

In this country croup is a rare disease, and the busiest physician 
meets ^vith it six or, at the most, ten times a year. It, therefore, ap- 
pears incomprehensible how so many physicians can speak of epi- 
demics of croup. To constitute an "epidemic," the sickening of large 
numbers of persons is certainly necessary, and this is never observed by 
us as respects croup. The period of life most susceptible to croup ex- 
tends from the first to the twelfth year, the majority of the patients 
being between the second and seventh year. In the nursling age it 
occm-s extremely infrequently, and the histories of cases to which no 
post-inoHe)n report is annexed, therefore, merit very little reliance, 
because it is very easy to confound it with spastic affections of the 
larynx, so common in this age. 

Tlie course of the disease is extraordinarily rapid. The shortest 
time I have known, from the invasion of the malady till death, was 
twenty-one hours; the longest, eight days. The termination is 
almost always fatal. I have never yet seen a child recover from the 
genuine fibrinous croup, but from the diphtheritic form three children 
out of twenty or twenty-five have recovered. In these cases, the chil- 
dren did not fully regain their strength till after many weeks ; the 
hoarse voice and barking tone of the cough remained longer than the 
rest of the symptoms. Nothing could be seen of any expectorated 
nor vomited membranes, notwithstanding the most careful and con- 
stant watching. The symptoms began to subside in from eight to 
ten days from the beginning of the disease, and passed off gradually ; 
their ability to partake of some lukewarm milk, without being subject 
to paroxysms of coughing, was slowly regained ; the fever abated, the 
dyspnoea diminished so much that they were able to lie down, and to 
sleep a few hours at night. The urine was discharged in larger quan- 
tities, with copious precipitates of urates. For a long time they re- 
mained very pale, emaciated, and debilitated. 

I am unable to answer the question, in regard to relapses of croup, 
from personal experience, for my three recoveries, one of which re- 
lapsed, will certainly not allow me to form an authoritative conclusion. 
The most experienced authors, such as Valleix and Guersant^ express 
themselves against the possibility of relapses, but Most relates a case, 
in which genuine croup occurred twice in the same child, and, on both 
occasions, eventuated in the expulsion of membranes. When some 
mothers relate that their children have had the croup five and six 
times, they no doubt announce the result of an intentional or uninten- 
tional deception on the part of the attending physician. I once at- 
tended the children of a family, the oldest of whom, it was said, had 



260 DISEASES OF CHILDREN. 

suffered croup six times in early life. Three times the child was 
treated by the then family physician by venesection, and the other 
three times by leeches, the cicatrices of which were still visible in 
large numbers on the neck, and, on every occasion, numerous emetics 
were administered. The results of this oft-repeated, energetic treat- 
ment were — in the case of one of the children, a boy — that he has 
been very much dwarfed in body, is constantly ailing, and is also very 
slow in developing his mental faculties. When one of his younger 
sisters fell sick with croup, as the mother supposed, she sent for me, 
but, instead of croup, I found only a feverless catarrhal laryngitis, 
with hoarseness, croup-cough, and croujDy breathing. Under a simple 
treatment, with solution of carbonate of soda ( 3 j to water 3 iv), a 
tablespoonful every hour, all the symptoms subsided in a few days. 
In the course of two years, this affection recurred in tliis child several 
times, yet the same treatment was always adopted, with the same 
favorable result, and the child has not been disturbed in its develop- 
ment in the least. The shrewd mother maintained that the croup-at- 
tacks of her older child differed in no respect from those of the younger, 
except that the former was always a much longer time in recovering 
from each attack; this difference, as well as defects of development, 
she no doubt justly attributes to the former methods of treatment. 

The prognosis in well-declared croup may be set down as fatal. 
It'is most unfavorable in purely fibrinous croup occurring in hitherto 
healthy, well-developed children. Such children enjoy no advantage 
over feebler ones in tliis disease, except that they are often able to 
resist its destructive force a day or two longer, but they perish just as 
surely. In diphtheritic croup, especially after measles, a recovery 
now and then takes place, upon which the treatment, as we Avill see 
further on, has no very remarkable influence. Where collapse, cyano- 
sis, and an uncountable pulse have supervened, there sjDeedy death 
may be prognosticated with certainty. 

Treatment. — There is no disease, with the exception of epile^Dsy 
perhaps, in which so many remedies and methods have been recom- 
mended as in croup. This analogy is not only remarkable in regard 
to the diversity of the remedial agents, but also in regard to their 
efficacy in these two diseases. 

The older school of the present century, which regarded every 
patient suffering from an inflammation as lost, unless a large quan- 
tity of blood could be extracted, insisted, of course, that in laryngeal 
croup — ^the most acute of all inflammations — venesection and leeches 
should be employed. This was carried out to such an extent that 
even the jugular vein was advised to be opened, because from it 



DISEASES OF THE RESPIRATORY ORGANS. 261 

more blood could be obtained, and only the difficulty attending the 
arrest of the bleeding from it served to prevent this measure from 
being generally adopted. In phlebotomy, one and a half ounces of 
blood were counted for every year of life, twice as many leeches were 
always applied as the child numbered years, and the region of the 
sternum Avas preferred to the neck, because on the latter no compres- 
sion could be exercised, and it might, therefore, be difficult to arrest 
the haemorrhage. I am not able to speak of the effects of venesection 
from my own experience, for I have never seen a child with croup 
treated in this manner. But it is now discarded as inadmissible, even 
by the advocates of venesection in general. I have often already no- 
ticed the effects of leeches, and must candidly confess that they do 
decided harm. The patients are very much frightened at them, and 
strive, with all their might, against their application. As a result, 
the dyspnoea and suffocative attacks are rather aggravated than 
diminished, and collapse is generally hurried on. But, if the phy- 
sician err in the diagnosis, a very possible occurrence in the early 
stages of the disease, and it is only in this stage that any benefit is 
claimed for the application of leeches, there is great hability of apply- 
ing them in cases of laryngeal catarrh. This would be not only a use- 
less application, for the disease gets well without them, but one which 
would probably materially retard convalescence. 

Emetics in croup have always found decided favor with most phy- 
sicians, although the entertained theories of their action have been 
as various as the size of the doses and manner of employing them. 
While some seek a specific effect in remedies which produce emesis 
— in tart, emetic.^ in cup. sulphur.., and even in ipecacuanha — others 
regard the act of vomiting, induced by these agents, as the essential 
result. The advocates of the first doctrine disputed for a long time 
with each other whether tart, emetic.^ or cup. sidph.., alum^ or zinc. 
sulph.^ were the best remedy ; whether the disease must be attacked 
by larger or minute doses. Under these circumstances, many extrava- 
gant, absm-d, and protracted therapeutical torturings of children with 
croup took place. These unfortunate victims of incessant dyspnoea 
had, therefore, to struggle through the last days of life against an 
equally unbearable condition, viz., constant nausea, i. e., against an 
artificially induced sea-sickness. Nauseants, therefore, having proved 
inelncacious, to continue to administer them in small doses is un- 
justifiable. 

It has also been claimed that it was difficult to make children with 
croup vomit, and that, therefore, they required larger doses for that 
purpose. But this supposition has reference only to that stage of 
croup which precedes the agony of death, in which the pulse is nearly 



202 DISEASES OF CHILDREN. 

imperceptible, and collapse is supervening. At tlie invasion, however, 
of the disease, thej will vomit from any em.etic like other children, 
and an infusion of ipecacuanha ( 3 j of the root to 3 j of water) will 
induce it. It cannot be denied that the act of vomiting, repeated one 
to three times, often has a very good effect upon the dyspnoea, by ex- 
pelling from the larynx loosened membrane and accumulated mucus. 
Its effect is not curative, of course, for the exudations are usually re- 
produced, and the former dyspnoea, with all its accompanying sjmip- 
toms, recurs. And yet, even when no membranes are expelled with 
the act of vomiting, temporary mitigation of the dyspnoea is neverthe- 
less observed in many instances, so that the act of vomiting seems to 
have a favorable influence upon the inflammatory swelhng of the 
glottis itself. For the purpose of exciting vomiting once or twice, 
ipecacuanha answers sufliciently well. The more jDowerful doses of 
tart, eniet. or of cuj). sulph.^ that are given subsequently, it is true, 
produce more vomiting, but they seldom bring about any amelioration ; 
on the contrary, they lead to rapid collapse. The sweetened infusion 
of ipecacuanha, which children take without any objection, has the 
additional advantage that it much less frequently induces diarrhoea 
than those mineral salts. I generally give such an emetic once or 
t^^-ice as soon as I come to a case of developed croup, but regard it as 
useless torture to nauseate the patients for any length of time after- 
ward. 

For a long time sulphuret of potassium enjoyed the reputation of 
being a specific against croup, and seems to have become famous 
mainly through one of the Napoleonic prize competitors, who sent in 
his work anonymously, having recommended it as the only remedy 
for croup. But the ineffectualness of this remedy has become appar- 
ent in so many cases that it is now altogether abandoned. Its dose 
was one-half to one grain every hour. Next to the emetics, mercury 
was the most frequently-used remedy. Blue ointment was rubbed in 
upon the neck, over a larger or smaller surface of the thorax, and 
calomel was given in larger or smaller doses internally. When the 
pecuhar action of mercurial preparations is desired to counteract the 
inflammation of the larjmgeal mucous membrane, its use is rational, 
and the treatment is sustained by manifold analogies ; but, when 
calomel is given in large doses for the mere purpose of accomplishing 
a derivative action on the bowels, it is more injurious than the neutral 
salts, or small doses of drastic remedies. Of the few cases which I 
treated with mercury internally and externally, one recovered. That 
was a gu'l, five j^ears of age, but in whom leeches and several emetics 
were also used, so that this result, as regards mercury, must be stated 
to be a very uncertain one. 



DISEASES OF THE RESPIRATOHY ORGANS. 263 

The alkaline carbonates have been long recommended in croup, 
on account of their solvent properties, wliich they exercise over all 
animal substances, consequently also over croup-membranes. Sellweg^ 
Yoss^ X>orfmueUei\ Eggert^ Hufeland^ and many others, have ex- 
pressed themselves in their favor, and, lately, Liizsinsky^ of Vienna, 
has appeared as a special advocate of carbonate of potassa. He gives 
two scruples, or one drachm, of this remedy in solution pro die^ and 
ascribes to it specific effects. His thel-apeutic measures consist (1) 
in neutralizing the morbid" admixture of the blood by the potas. carbon. ; 
(2) in overcoming the localization of the inflammation in the larynx, 
by a bhster on the upper part of the sternum, kept in a state of con- 
stant suppuration ; (3) in moderating the dyspnoea and the cough- 
paroxysms by opium ; and (4) in cauterizing the existing membranes 
with nitrate of silver, and in causing their expulsion by emetics. 

Although I am unable to confirm the specific effects of carbonate 
of potassa — for, of five cliildren which I treated very scrupulously ac- 
cording to X/uzslnsJcy'' s method, I was only able to save one — still, this 
method of treatment has much advantage over the older method with 
leeches and emetics, for by it the children are not tortured, and, to say 
the least, just as many, and probably more, are saved by it. 

The other methods of treatment, with quinine, with large doses of 
narcotics, by the hydropathic method, etc., each of which has ,a suffi- 
cient number of advocates and detractors, I have not tried, and 
therefore refrain from giving any decided verdict upon them. 

The local treatment has already experienced manifold variations. 
Some wrap up the neck in dry, others in wet woollen cloths, or 
in moist sponges, or even in swallows' nests boiled in milk (a famous 
popular remedy). Others cause the neck to be coated with a layer 
of fat from all imaginable classes of animals, others again apply vari- 
ous counter-irritants, and still others maintain that the dyspnoea is 
less severe when neck and breast are entirely uncovered. The French 
physicians always place great value upon Mretonneaii) s cauterizations 
of the larynx. For this purpose a proper whalebone rod, with a bit 
of sponge secured to one end, is made use of. The sponge is dipped 
in a solution of lunar caustic (3ss — 3 j to water | j) and then intro- 
duced into the pharynx, the tongue being depressed with a S23atula as 
much as possible. The sponge is allowed to tarry upon the epiglottis, 
and by a slight pressure some of the solution is squeezed out upon it. 
No special admonition is necessary about the corroding of the larj-nx, 
and the slipping of the sponge into the glottis between the chordae 
vocales, because for this purpose a spontaneous deep inspiration is 
requisite, during which the epiglottis rises high upward, which is 
hardly possible with the. sponge in the mouth. The solution of 



264 DISEASES OF CHILDREN. 

nitrate of silver has a decidedly favorable efiPect upon tlie inflamed 
mucous membrane wherever it comes in contact with it, causino- it. 
as a rule, to cast off its false membranes in the course of twenty- 
four hours, and thenceforth it often remains free from further 
formation. But in genuine fibrinous croup I have seen no effects 
whatever from the cauterization of the pharyngeal mucous membrane, 
which indeed is generally unimpaired. Besides the solution of lunar 
caustic, powdered alum, red precipitate (one jDartto twelve of sugar), 
sulphate of copper, and calomel, have also been blown into the pha- 
rynx. 

The air of the room in which these patients are confined should be 
pure and moist, and that is best secured by repeated ventilations, and 
by evaporating water in a shallow vessel. 

As a resume of what has already been said, I will here briefly no- 
tice the methods of cure advocated by the principal authors, without, 
however, committing myself to a belief in the efficiency of any indi- 
vidual remedy : 

(1.) JuTine. — In the first stage, abstraction of blood, according to 
the character of the attack and the state of the system ; after the first 
abstraction of blood, mild emetics, these to be continued in fractional 
doses during the second stage (in dyspnoea and sufibcative attacks). 
Should the symptoms grow worse, sinapisms and blisters upon the 
neck, breast, etc., and moist atmosphere to assist the inspiration. 
In the second period, emetics in full doses, and subsequently strong- 
expectorants and antispasmodics, according to circumstances. 

(2.) Groelis. — Leeches, calomel in large doses, inunction of %mg. 
ciner. upon the neck and breast ; in the interval, nitre / early vesica- 
tions ; in dyspnoea, emetics. 

(3.) Hufeland. — First his linctus emeticus (tart. emet. gr. j, ipe- 
cac, powder 3 j to 3 ijss mixture). Warm^ moisture, combined with 
saltpetre, and clysters of one tablespoonful of wine vinegar. When 
the dyspnoea becomes aggravated notmthstanding (just what actually 
occurs uniformly in genuine croup), sulphate of copper in emetic doses, 
in \ gr. doses every two hours, and so on at each exacerbation, inunc- 
tions of mercury on the neck, and counter-irritants. 

(4.) Liizsinsky. — The diagnosis having been determined, a bHster 
at least the size of a silver dollar upon the manub. sterni. Internally 
80I, kali carho7i. ( 3 j to water 3 iv), to be consumed in twenty-four 
hours. To cover the blister with epispastic paper and keep it suppu- 
rating as long as possible. In very severe dyspnoea, small doses of 
morphine ; an emetic during severe suffocative attacks. Cauterization 
of the pharynx with nitrate of silver. 

This last method, with the exception of the blistering, has the great 



DISEASES OF THE RESPIRATORY ORGANS. 265 

advantage of not torturing the patients, and therefore ought to be pre- 
ferred to all others. But if after repeated trials it should become mani- 
fest that it is totally inefficient, then it would be inhuman to continue 
it. As a natural result of the ineffectualness of those remedies hitherto 
used in croup, new ones will probably be constantly tried. 

Finally, a few words about tracheotom}^. The idea of making a 
passage for the air through an opening in the trachea in persons who 
are about to suffocate from obstructions in the larynx, is very old, and 
as regards its practice in croup it is almost as old as the knowledge 
of croup itself, for Some pointed out this indication as early as 1765. 
Since that time, the operation has been performed from time to time, 
but always with unhappy results, so that the prize competitors of 1807 
could only mention one successful case, but that was a case in which 
the diagnosis is said to have been questionable. In 1823 JBretonneau 
again set the operation in motion, and since that time it has been con- 
stantly performed and defended by some of the French physicians ; but 
it is necessary to observe here, that the majority of the operations 
were performed in hospitals for children where contagious diphtheritis 
prevailed. While many of these croup patients operated upon recov- 
ered, it is also true that recovery without tracheotomy often took place. 
Up to the year 1842, Troussecai had operated 119 times, and out of 
that number obtained 25 recoveries. At this time the principle was 
advanced that the operation must be performed very early, whereupon 
the ratio became so favorable that 14 recoveries occurred out of 24 
operations. According to another compilation, by Isamhert^ 47 out of 
216 cases operated upon recovered, or 22 per cent. This doctrine 
loses much of its force by the circumstance that the operation must 
be performed so early in the disease that the practitioner, still less the 
surgeon, is unable to positively state if the case be one of croup or 
catarrhal laryngitis. In Germany, it is true, there are a few solitary 
advocates of the operation, Jtoser and Passavant^ for example ; but 
the majority of the physicians experienced in the treatment of the dis- 
eases of children, and also most of the German surgeons, do not per- 
form tracheotomy in croup. In England the opinion is generally 
against it, and in France a reaction seems to be rising up against it, 
for Bouchut ( Gazette Medicale^ 1858, No. 41) has shown that for every 
1,000 inhabitants in Paris, the number of deaths from croup increased 
from year to year, and was never so great as in the last decennium. 
In 1853 twice as many children died from croup as in 1837, and, from 
the years 1847-1858, on an average y?ve times as many as in 1838 ; 
while, according to a proximative calculation, no such increase of the 
disease as fivefold has occurred. He lays the blame of this great 
mortality directly upon the present local treatment, the escharotic, and 



2QQ DISEASES OF CHILDREN. 

traclieotomj. The reason why the operation has so httle favor with 
us in Germanjj and also in England, is, that we really have few diph- 
theritic, but mostly genuine fibrinous croup patients. 

The operation itself is not attended by any danger to life, and, 
according to Trousseau^ is performed in the following manner : 

The child is laid upon the table, and under its shoulders a pillow 
is placed, supporting only the neck, so that the head may hang down 
a little backward, and the trachea be properly stretched. A longitudi- 
nal incision one and a half inches long is now made, commencing at 
the cricoid cartilage, and carried straight downward. The lips of the 
wound are retracted with blunt hooks, due attention being paid to 
the veins, which are also drawn aside by the blunt hooks. After the 
trachea has been sufficiently exposed, to an extent of three to four 
cartilages, which are recognized by their white appearance and greater 
resistance, a blunt-pointed bistoury, the dilator, and the double canula, 
especially made for tracheotomy, are then got ready. An incision is 
now made into the trachea, the opening is dilated, and the canula is 
then introduced by slipping it in between the separated branches of 
the dilator. After the operator has convinced himself that the air 
passes through the tube, the dilator may be removed, and the canula 
is secured by the aid of a tape, and the child, which has suddenly com- 
menced to breathe freely, is allowed to rise. 

Of the serious accidents liable to occur during the operation. Trous- 
seau mentions, first of all, hoemorrJiage. Venous haemorrhage is con- 
trolled by simple compression with the finger, and ceases as soon as 
the canula is introduced ; arterial bleeding, of course, must be arrested 
by the ligature. The anxiety about the blood finding its way into the 
trachea, on the whole, seems to be somewhat exaggerated, since in 
patients with haemoptysis a certain quantity of blood necessarily must 
remain in the trachea and bronchi, but it generally does not induce any 
particular sufi'ocative attacks. 

Syncope very frequently occurs after the operation, and is produced 
by the sudden disturbance of the cerebral circulation, in consequence 
of the respiration having suddenly become free. Trousseau once saw 
it last one hour, but never terminate fatally. 

If the respiration does not improve after the operation, the canula 
will be found to be blocked up with blood coagulas or pseudo-mem- 
branes, which must be removed by means of a forceps made for that 
purpose. 

In the after-treatment, the greatest attention is to be bestowed 
upon the canula. The wound should be covered with a piece of oiled 
silk, with a hole in the centre to admit the tube ; a second canula is in- 



DISEASES OE THE RESPIRATORY ORGANS. 267 

trodiiced into tlie first, so that, for the purpose of cleansing, the whole 
apparatus' need not be removed ; and a thin cloth is tied around the 
neck, in order that the air may not come directly m contact with the 
tracheal mucous membrane, but first be purified from dust by passing 
through the cloth. The canula should be taken out every three or 
four hours and cleansed. Once only Trousseau was able to remove 
the canula permanently on the fourth day, several times on the sixth 
and eighth, generally between the tenth and thirteenth, once not till 
the forty-second, and once after the fifty-third day. No tracheal fistula 
ever resulted from the operation. 

Childi^en eat and drink immediately after the operation, and 
without any difficulty. Four or five days later, however, a spasmodic 
cough comes on every time drink is taken, and part of the liquid 
is expelled through the canula, a proof that the epiglottis is not able 
to perform its functions as thoroughly as in the normal state. This 
condition lasts one or two weeks and then subsides. In serious suffo- 
cative attacks. Trousseau forbids all liquid nutriments. 

So much about the execution of this most unfavorable of all oper- 
ations, which I, for my part, never insist upon, nor directly oppose 
when proposed by other physicians, and still less by the parents them- 
selves. 

Let us assume that all the children operated on had genuine croup, 
the ratio of recoveries of twenty-two per cent, is nevertheless an ex- 
tremely unfavorable one, and especially since the greater portion of the 
children operated on suffered from the milder diphtheritic form. And 
if we take into consideration the additional fact that the majority of 
physicians experienced in children's diseases have abandoned the oper- 
ation in croup, on the ground that it is a general disease, with locali- 
zation upon the larynx, we must, it appears to me, discourage its prac- 
tice generally, and close with the following words from old Goelis : " Ad 
tracheotomiam, omnium remediorum incertissimum confugere res ardua 
est ; parehtes abhorrent, aversantur agnati et periclitatur medici fama, 
quern, infausta si fuerit operatio ao votis illudens, lacrymis multis velut 
homicidam prolis amatae detestantur parentes." 

(2.) PsEUDO-CEOTJP {Laryngitis Gatarrhalis). — When an adult 
contracts a catarrh of the larynx, he becomes hoarse, has a tickling 
and itching sensation in the larynx, and along w^th that coughs, but 
dyspnoea and fits of choldng do not occur, as a rule. If a child, on the 
contrary, falls sick with a simple catarrhal swelling of the laryngeal 
mucous membrane, violent disturbances of the respiration immediately 
set in, having their foundation in the narrowness of the chink of the 
infantile glottis. There seems to be a different relation in the larvnx of 



268 DISEASES OF CHILDEEN. 

the child, between the swelling of the mucous membrane and width 
of the chink of the glottis, from that which exists in the adult. While 
the glottis of the latter still tolerates a certain degree of catarrhal in- 
filtration, without inducing any very severe dyspnoea, it very often 
happens that children, who are scarcely noticeably hoarse, are sudden- 
ly attacked by fits of suffocation, and for the time present a deceptive 
similarity to genuine fibrinous croup. 

Symptoms. — There is a very simple catarrh of the nose or bronchi, 
or of both at the same time ; the patients are comfortable the whole 
day through, and eat -with the customary appetite, and, aside from a few 
sneezes and coughs, are in perfect physiological condition. They fall 
asleep at the proper time, cough perhaps a little during the sleep, or 
snore in an unusual manner, but suddenly wake up with a well-marked 
attack of croup. Croupy cough, hoarseness, croupous respiration, and 
very violent choking-fits, immediately come on, and now no person is 
able to distinguish this affection from genuine cfloup. The same amdety 
and oppression also supervene ; the child rises to a sitting posture, 
the face becomes red, and the pulse considerably accelerated. These 
symptoms last for one, or at the longest two hours, and then begin to 
subside ; the breathing and the voice become almost normal, the child 
hes down again, may call for drink, and then fall asleep, during which 
a general perspiration breaks out. The physician, who usually arrives 
at the house about this time, finds a perfectly healthy, sleeping child, 
who wakes up very indignant at again being disturbed in its night's 
rest. Two or m.ore attacks seldom take place in one night, but 
they generally recur in the following nights, and sometimes even 
after they have been absent for many days or even weeks. Slight 
hoarseness, a barking cough, and loud snoring during sleep, gen- 
erally remain after the attack ; the temperature of the skin on the 
hands and forehead may, it is true, be slightly elevated, but actual 
fever, with general malaise and great depression, does not occur. Chil- 
dren thus attacked desire to leave the bed and partake of their meal, 
although not with a full appetite. Strange to say, no violent attacks 
ever occur in the daytime ; a fact due perhaps to the greater sensibil- 
ity of the larynx to the masses of mucus accumulating within it during 
sleep. In the daytime, as soon as this accumulated mucus is of any 
amount, it excites cough-paroxysms, and is finally coughed out from 
the larynx into the pharjmx, while at night it remains there for a 
longer time, and then induces violent reflex phenomena. 

The entire duration of the affliction is from three to eight days. The 
usual, indeed almost invariable, termination is in recovery ; but cases 
also occur in which children for many days display distinct catarrhal 



DISEASES OF THE RESPIRATOIIY ORGANS. 269 

lannagitis, but finally, under aggravation of the general disease, fall 
into genuine croup, which generally terminates in death. At the au- 
topsy, membranes are not commonly found in these cases, nothing 
more than a marked swelhng and reddening of the laryngeal mu- 
cous membrane, and upon it, as well as upon the tracheal and 
upon the phar^Tigeal mucous membrane, a thick coating of tenacious 
mucus. 

Pseudo-croup is very much disposed to relapses, as is often learned 
from the statements of adults, who claim to have had the disease six 
and eight times in their youth. It most frequently attacks children 
in whom the eruption of the last molares is in progress, but does not, 
however, sj^are older ones ; while in small children, who still labor under 
the effects of cutting the incisor teeth, the spasmodic form of laryngeal 
affection, without any catarrh, is the most frequent variety. More- 
over, there are also transitory forms in which it is very difficult 
to decide whether we have to deal with a simple spasm of the 
glottis or pseudo-croup. Only the hoarseness of the voice and the 
croup-tone of the cough in the intervals allow the diagnosis for this 
or that form to be established with certainty, for these symptoms 
never occur in pure spasms of the glottis. Pseudo-croup is also dis- 
tinguished from genuine croup by its intermittent character. Al- 
though in the former the voice in the daytime is hoarse, and the 
cough affected with a croupy clang, still the fever and the general 
affection will never awaken any special anxiety ; the children get up, 
are lively, amuse themselves with their playthings, and even partake 
of some nutriments. But from all this the case is totally the reverse 
in genuine croup, and the laryngeal symptoms are always much more 
pronounced. 

Treatment. — Pseudo-croup should never be regarded slightingly 
even in its mildest form ; for very gradual transitions into the genuine 
croup happen, and, after the fatal termination of which, we may, when 
too late, regret having carelessly treated the first hoarseness. Chil- 
dren thus affected are to be kept in a perfectly uniform temperature ; 
the neck should be wrapped up, and they should be confined to a 
milk diet and plain soups. Moist compresses to the neck, when prop- 
erly applied, act very favorably. The compress should be no A^dder 
than a narrow cravat, covered by a piece of gutta-percha, and these 
confined around the neck by a second dry cloth in such a manner that 
the water will not run down upon the body, and cause a too rapid 
evaporation and partial cooling of the neck, by which the hoarseness 
generally becomes aggravated. This danger on the one hand, and 
the conviction that the wet cravat is not always absolutely necessary. 



270 DISEASES OF CHILDEEN. 

have induced me to discard it altogether where a special and expe- 
rienced nurse does not undertake the care of the child. Internally, I 
generally give kali carb. (3ss — 3j to water 3 iv), and allow the pa- 
tients to drink as much as possible, because experience has proven 
that, by promoting diuresis and diaphoresis, a mitigation of the ca- 
tarrhal secretion of the respiratory mucous "membrane is produced. 
It will seldom be necessary to resort to emetics. 

(3.) Netieosis of the Larynx. — Motor disturbances of the 
laryngeal muscles frequently and almost exclusively occiu* in childhood. 
Both forms, the spasm and paralysis, are observed, but the former is 
much more frequent than the latter. It must be premised that, as a 
rule, all those laryngeal affections must be excluded in which any 
symptom of material lesions of the mucous membrane can be de- 
tected; for, since the muscles of the larjTix must by such lesion 
become altered, a change of the voice follows, as well as a change in 
the manner of breathing, and in the cough. These exclusions hav- 
ing been disposed of, the neuroses remain. In slighter deviations 
from the normal construction, which, in the cadaver, presents a path- 
ologically altered mucous membrane, it is often difficult to decide 
whether death resulted from a pure neurosis, or from a swelling of 
the mucous membrane, or an oedema of the glottis. 

(a.) SjKismus Glottidis. — That the glottis may become spasmodi- 
cally contracted is no longer any subject of doubt. This may be 
demonstrated experimentally by -vivisections, and is anatomically con- 
firmed by the insertions of the muscles of the larynx. TJiese muscles 
are supplied by the recurrent laryngeal nerve, and are (1), the thyro- 
arj^tgenoidei ; (2), the cricoarytaenoidei laterales ; and (3), the aryt^- 
noideus transversus. 

An acute and a chronic form may be distinguished. There are 
spasms of the glottis in which death ensues, after the first few par- 
oxysms, by choking or suffocation, and others again which last for 
months, and may relaj^se after very long pauses. The writers of the 
preceding and of the present century record no precise reports con- 
cerning this condition, but differ remarkably from each other in their 
views upon it, and consequently have invented a number of names, 
most of wiiich are based upon etiological -vdews, causing the greatest 
confusion in the minds of those physicians who do not rely upon their 
own investigations. Thus there was an asthma acutum et chronicum 
]\Iillari, the symptoms of which, however, are more applicable to our 
own pseudo-croup than to a pure spasmus glottidis — an asthma thy- 
mico-cyanoticum — a suffocatio stridula — an angina stridula — apnoea 
infantum — catalepsis pulmonum (Hufeland) — a laryngismus stridulus 
— phreno-glottismus — larjTigo-spasmus infantilis — tetanus apnoicus 



DISEASES OF THE RESPIRATOKY ORGANS. 271 

infantum — and finally even a cerebral croup, by wliicli the English, 
especially Clarlx^ understood a species of croup, at the autopsy of 
Trhich the larynx was found unaffected, and which, of course, vfas al- 
ways ascribed to a cerebral disease that was not demonstrable. 

Symptcms. — Tlie following morbid picture may be delineated in 
general outlines. Usually very healthy, robust children are seized 
during the process of dentition w^ith a suffocative attack. All at once 
the face becomes strongly injected, the head is thrown backward, the 
mouth is slightly open, or makes snapping movements ; the extremi- 
ties are stiff, or hang down powerless ; the child also plucks at its 
neck, as if it would tear away the cause of its strangulation. Finally, 
after a most tormenting struggle of a half to one minute, a few short, 
abrupt whistling inspirations follow, with which no expirations alter- 
nate, and then the whole fit is either at an end, and the normal respira- 
tion inducted again by a prolonged whistling expiration, or another 
suffocative attack, with totally arrested respiration, begins. This entire 
phenomenon may recur several times in succession, so that the child 
does not return to normal or much improved respiration for several 
minutes. The paroxysms occur as often in the daytime as in the 
night, and may return forty times in the twenty-four hours ; they 
are especially induced by deep inspirations. If the disease has ex- 
isted for a certain time, general convulsions will become superadded 
to the spasm of the glottis — a condition which has been described by 
some authors as the second stadium. 

If we are to analyze the individual symptoms more accurately, it 
will be necessary to classify them first into two groups: (1), as to 
the symptoms during the attack, and (2), the symptoms in the inter- 
vals. 

(ad 1.) The tone which accompanies the first inspiration after the 
suffocating fit, and at the beginning of the cataleptiform state, popu- 
larly called " Ausbleiben " in German, is always very characteristic. 
It is a cromng, whistling cry (the crowing inspiration of the English), 
and is tolerably accurately imitated by executing a sipping inspira- 
tion through the almost-closed chink of the glottis, while at the same 
time attempting to utter the vowel i. Sometimes this cataleptic state is 
also ushered in by a few of these inspirations, but, in most instances, 
the children have not the time for that, and, as if strangled, gasp 
voicelessly for air, along with which they become livid, and throw 
the head backward, in order to dilate the chink of the glottis as much 
as possible. Immediately after the attack, the expirations are super- 
ficial and apprehensive, but soon become perfectly normal, and free 
from the whistling noise heard in croupy breathing. 

The superaddition of general convulsions to spasmus glottldh 



272 DISEASES OF CHILDEEX. 

(second stadium), as relates to prognosis, is very imjDortant. Tlie 
thumbs are now drawn in toward the pahns, the forearms strongly 
pronated, and all the adductors of the upper extremities affected with 
spasmodic contractions. The feet, on the contrary, are rigidly ex- 
tended, the great toes abducted and di'a^yn upward. The muscles of 
the face are tlirown into convulsive action, and opisthotonos may ap- 
pear. The temperature of the extremities is much more likely to be 
diminished than increased. These general convulsions plainly depend 
upon those of the glottis, for they appear and disappear vrith them. 

During the paroxysm, the face, of course, becomes flushed and even 
cyanotic. The congested eyeballs protrude from their cavities, the 
tongue becomes bluish-red, and the veins of the neck distended, and 
the face is stamped Avith the expression of the utmost anxiety. 
During the attack itself it is very difficult to feel the pulse, or to dis- 
tinguish by auscultation the sounds of the heart. Indeed, such an 
examination, at a moment of so great danger to life, is not onlv use- 
less, but improper and cruel, and should not be practised at such ex- 
pense of' most precious time. Several minutes after the paroxysm 
the pulse is still chstinctly felt to be unrhythmical and irregular. The 
fseces, and less frequently the urine, are passed involuntarilj^ during 
the paroxysm. 

(ad 2.) The symptoms during the intervals are different, according 
to the severity and the duration of the paroxysms. Most children, 
during the interval, are tired and petulant, but in the mild cases ap- 
petite and sleep are enjoyed. In those instances where the spasms 
are intense and frequently repeated, the child loses its appetite, be- 
comes emaciated, and suffers more or less fever. 

Duration, Course, and Prognosis. — The duration of this disease 
cannot be fixed at any given time. Sometimes even the very first at- 
tack terminates in death, and a seemingly perfectly healthy child may 
be carried off in a few seconds. Others may suffer for months, pe- 
riodically, as often as a tooth breaks through, from a crowing, whist- 
ling inspiration, not, however, from total closure of the glottis, and 
its extreme symptoms, as the normal respirations recur after a few 
seconds. In most cases, the disease iTins through a certain circuit, in 
which an aggravation, a climax, and a diminution, can be recognized. 
At first the attacks are rare, recuning every eight or fourteen days, 
but in the process of time they become more frequent, finally occur 
several times daily, and increase in intensity. Before this climax has 
been reached, six to eight weeks generally pass away. The chil- 
dren either perish in a fit, or, when this acme has lasted for from eight 
to fourteen days, are attacked by fever and become emaciated. A lobu- 
lar pneumonia or a profuse intestinal catarrh may come on, and result 



DISEASES OF THE RESPIRATORY ORGANS. 273 

in death. Recovery, unfortunately, happens very seldom when the 
disease has once passed beyond a certain grade of severity. In the 
favorable case, the paroxysms remit in frequency and finally cease 
altogether. But the child remains very backward in its development, 
is always pale, rachitic, and predisposed to relapses, which, however, 
seldom terminate unfavorably. Out of fifteen cases of which I have 
kept a record, eight died. Hilliet and Sarthez, out of nine cases, and 
Herard out of seven, observed in each only one single instance of re- 
covery. It may be safely assumed that this relative mortality had 
turned out rather too unfavorable, since only the serious cases under 
the care and watchful eye of the physician are taken into account ; 
and the milder forms, which gave the physician but little trouble, 
and caused the parents no great anxiety, are probably not men- 
tioned. 

The prognosis depends upon the frequency and intensity of the 
attacks, upon the complication, and upon the comparative development 
of the child. Children at the breast recover oftenest ; thin, emaciated 
children, and those inclined to atrophy, very rarely. The more de- 
veloped and extensive the craniotabes is, the more unfavorable is the 
prognosis ; the connection between it and spasm of the glottis w^ill 
be more thoroughly discussed in the following section. 

Etiology. — We have to discriminate [between the causes which 
give rise to, or favor the single paroxysms, and the general exciting 
causes which are particularly predisposing to the disease. 

To the first belongs fright. A loud, suddenly-produced noise suf- 
fices to induce a spasm of the glottis. It may also be produced by 
depressing the tongue in the examination of the mouth, by the acts 
of deglutition, by coughing, and by crying. But the closure of the 
glottis brought about by crying should be carefully distinguished from 
that cataleptic state into which very choleric and somewhat older 
children, from two to four years of age, are voluntarily able to work 
themselves. There are very manj^, chiefly badly-brought-up, spoiled 
children, who at the slightest provocation throw themselves into vio- 
lent paroxysms of crying, and exert themselves so forcibly that they 
are for a moment unable to draw their breath, and for an instant be- 
come livid or even bluish-red in the face, and then begin their cry 
anew with a whistling, prolonged inspiration. This kind of voluntary 
unconsciousness is by no means dangerous, and there is no reason at 
all why the will of such children should be humored in order to avoid 
this condition. The most rapid psychological method of treating it 
is, to dash a glassful of cold water at once into the face. 

When the disease reaches its climax, it will require no active 
cause to induce a paroxysm. Then the attacks come on during the 
18 



274 DISEASES OF CHILDREN. 

calmest sleep, under tlie quietest circumstances, and at any time, with- 
out the least exciting provocation. 

By analyzing the general causes^ very peculiar phenomena are elu- 
cidated. First of all, as regards the sex, spasmus glottidis attacks 
boys much oftener than ghls ; a fact almost all authors admit. 
Out of my fifteen cases, eleven were boys, so that it seems as if the 
larynx of male children begins even in the very earliest youth to dis- 
tinguish itself in form, or at least in physiological activity, from that 
of female children. 

The age at which the disease occurs fluctuates between one half 
and three years ; that is to say, it makes its appearance with the erup- 
tion of the first tooth, and disappears with that of the last. It occurs 
much oftener Avith the cutting of the incisor teeth, in the first half year 
of life, than with that of the canine and molar teeth. The thought 
constantly suggests itself, whether a direct extension of the reddening 
and swelling of the mucous membrane, as a result of dentition, to 
the larynx, might not be assumed. In that event, however, spasm 
of the glottis would, be most sure to occur where the local troubles 
of dentition are most perfectly pronounced. But this, according to 
my observation, is by no means the case. In most of these children 
I found the mouth not particularly reddened, and without profuse 
secretion. 

The hereditary character of spasm of the glottis is interesting. 
There are families in which all the children sufi*er more or less from it, 
and Powell even relates an instance where, out of thirteen children, 
brought up by the same parents, only one escaped the disease. The 
mothers of the children whom I have treated for this disease were all 
of a tolerably excitable nature, and often complicated the child's 
disease by indulging in their habitual hysterical outbursts. 

The connection between craniotahes and spasmus glottidis (teta- 
nus apnoicus) has been satisfactorily demonstrated by PJlsdsser, the 
discoverer of the soft occiput. Not the softness and depressibility of 
the occiput per se, but their effects, should be regarded as the exciting- 
causes, as the meninges may thereby degenerate into an abnormally- 
congested condition ; true plastic exudations are not generally found 
in children who died from this disease. The discovery of the rela'tion 
between these two diseases by Elsdsser was subsequently fuUy con- 
firmed by many authors, especially Lederer, and cases have even been 
recorded in which spasm of the glottis could be voluntarily induced 
by pressure on the softened places of the rachitic occiput. Without 
doubting altogether this mechanical cause, it can, nevertheless, only be 
regarded as an exceptional one ; for, if it had a general applicability, 
then the paroxysms ought to come on oftenest during sleep, when 



DISEASES OF THE RESPIRATORY ORGANS. 2Y5 

chilch-en lie with the occiput pressing the pillow, than in the waking 
state, when they are mostly carried about upright. But exactly the 
contrary is the case. The hypergemes of the brain, and of its mem- 
branes, upon which JElsdsser lays a particular amount of stress, are 
much more probably the effect than the cause of the disease, and when, 
ex juvantihus et nocentibus^ a conclusion might be made upon the 
nature of a disease, then they stand in no causal connection at all 
with the spasms, because otherwise these should be cured or palliated 
by local abstraction of blood, and by a derivative action upon the bow- 
els, a result well known to be impossible of achievement by these 
means. We must therefore limit ourselves to admitting the remark- 
ably frequent concomitance of spasmus glottidis with craniotabes, as 
irrefutable facts, but require further physiological and anatomo-patho- 
logical investigations, for the conclusive proof as to cause and effect. 

Disturhances of the digestion may likewise produce spasms of the 
glottis, as may be readily inferred from the fact that a sensible regu- 
lation of the diet, and abstaining from nutriments difficult to be digest- 
ed, bring about a speedy improvement ; while all treatment is fruitless 
so long as the digestion is attended by flatulence or diarrhoea, or other 
disorder. Children at the breast are extremely rarely affected by this 
disease ; and, of the artificially-fed children, mainly those who do not 
jDroperly digest the immoderate quantities of food allowed them suffer. 
That the children of affluent parents are totally spared by this afflic- 
tion, as mUiet has observed, in Genf, cannot be maintained by us in 
Munich. The children of poor people do, indeed, oftener fall sick 
with it, but it should not be forgotten that in all cities there are more 
of these than of rich. 

Finally, Kopp^ and, after him, a great number of physicians, as- 
sumed the thymus gland to be a cause, and, indeed, the only one, so 
that the description of " Asthma-thymicum Koppii " is even used at 
the present day by some of the older physicians. But pathological 
anatomy has overthro^vn this theory. A large thymus gland has often 
been found in the cadavers of children who have died from totally 
different diseases, and never suffered from spasm of the glottis ; and, 
conversely, in many cases where this was the cause of death, a normal, 
and even an atrophied thymus was observed. Hence, it seems that 
we must discard asthma-thymicum altogether, as a denomination of a 
disease. 

Pathological Anatomy. — So far as the larynx itself is concerned, 
the morbid appearance is invariably of a negative character, and thus 
the spasmodic nature of the disease is also confirmed by the post- 
mortem examination. The rest of the appearances are not constant, 
and consequently not characteristic. Rachitis is most frequently 



276 DISEASES OF CHILDREN. 

found and most extensively marked upon tlie occiput, and next in fre- 
quency on the ribs. The th}Tiius giand is sometimes large, some- 
times small, and at times undergoing complete absorption. In the 
intestines, solitary glandular indurations are sometimes found ; in the 
bronchi, catarrh, and, in the lungs, tuberculosis may also hare ap- 
peared. The bronchial glands, in particular, are degenerated into 
large, cheesy tubercles. Hj^Dertrophy and an injected state of the 
meninges are frequent morbid appearances. By some investigators 
the pneumogastric nerves have been found hardened, by others again 
soft. 

Treatment. — (a.) Prophylaxis. — When one or several children of 
a family have already perished by spasm of the glottis, the parents 
are naturally in a state of constant fear that they may also lose 
those subsequently attacked, and therefore declare themselves ready for 
any sacrifice by which this calamity might possibly be averted. In 
this respect the country air is particularly recommended, but it must 
be remarked that it is only useful during the few summer months, 
when children may actually be taken out into the free air, and 
that the mothers, in such cases, are very averse to parting with their 
family physician ; and, lastly, residence in the country by no means 
supplies a positive guarantee against the appearance of the spasms. 
I myself have twice been taken to the country to see children with 
spasm of the glottis, who were born there, and had never yet been in 
the city. Hence it seems more advantageous to leave the children in 
the house of the parents, and under the care of the regular family 
physician, where they can enjoy fresh air several hours daily in some 
neighboring park. Such children should be kept as long as possible 
at the mother's breast, at least till they have cut the first six in- 
cisors. The supervention of the occipital rachitis is sought to be 
averted by zealous ventilation of the room, by keeping the head cool, 
bathing it with water, and by aromatic baths. AU sorts of di- 
gestive disturbances should be remedied as quickly as possible by 
small doses of alkahne carbonates, to which a httle rhubarb may be 
added, when constipation is present. 

(b.) Treatment of the Attack. — One minute is but a short time for 
the selection and application of a remedy, and it is altogether incom- 
prehensible how some physicians would have us treat the attack with 
sinapisms, emetics, clysters of various kinds, and with warm baths, 
the preparation of which certainly requires a much longer time. 
The first thing to be done is to raise up the child, and throw 
the head backward, so as to give the larynx the most favorable atti- 
tude, and to remove all the tight clothes from the chest as quickly as 
possible. In the instances where I happened to be present at the 



DISEASES OF THE RESPIRATOEY ORGANS. 2YY 

paroxysms, I introduced the index-finger into the mouth, carried it to 
the posterior pharjaigeal wall, elevated the epiglottis, and then touched 
the chords© vocales, by which marked acts -of choking were instantly 
induced, and then the well-known whistling inspiration followed. 
Lay people, of course, are unable to execute these manoeuvres, and I 
therefore content myself by showing them how retchings may in- 
variably be induced by pressure upon the root of the tongue. The 
shock produced by inducing this act of retching is the only harmless 
remedy which will cut short the paroxysm. From affusions with cold 
water, and from the forcible to-and-fro swinging in the air, very much 
in vogue with the nurses, I have seen no decided effects ; chloroform is 
very urgently recommended by many physicians, especially by Cox 
and Smage. It seems to me, however, to be too dangerous an agent 
to be left to the use of the lay attendant. Tracheotomy, which has 
been suggested as a dernier ressort, with which to save the life of the 
child, can never be performed, on account of want of time. 

(c.) Causal Treatynent. — Such a list of remedies, for the subjuga- 
tion of the developed spasm of the glottis, has been recommended, that 
the very number alone must excite mistrust. Those still in greatest 
favor are : oxide of zinc in grs. ii — x pro die, argent, nit^ gr. -J — |- 
pro die, ainmoniate of copper^ asafoetida^ tr. moscliata^ aq. amyg- 
dal. amar.^ helladoniia, hyoscyamus^ opium, can7iahis indica, five 
drops every hour, and small doses of calomel. All of these reme- 
dies are uncertain, and have no specific efi"ects whatever, for the ma- 
jority of children perish notwithstanding the kind of treatment and 
remedies used. There is but one remedy by which the rachitis can 
be positively brought to a stand-still, and that is the raw, strongly- 
rancid cod-liver oil, and if the frequent concomitance of rachitis of the 
skull with spasm of the glottis is not lost sight of, then this agent has 
yet the greatest claim to a rational method of treatment. In fact, I 
have already seen three children recover by the use of ol. jecoris. It is 
to be regretted that it is very often not tolerated by the stomach, pro- 
ducing gastricismus and vomiting, on account of which, of course, it 
has to be discontinued.* 

Scarification of the gums, which the English make various uses 
of, has found but little favor with us. In one child, in whom, the two 
bicuspids were very nearly through, I performed it very energetically, 
but without the least efi'ect. The paroxysms occurred oftener and 
oftener, constantly grew more and more violent, and the child suc- 
cumbed, although the swollen gums had been completely removed, 
and the sharp edges of the teeth were plainly visible. 

* Hillier and B. F. Dawson give bromide of potassium, and claim to have seen good 
eflfects from it. — Tr. 



278 DISEASES OF CHILDREN. 

Combined with the internal administration o£ ol. jecoris, I have 
lately kept two children constantly in a mild camphor-atmosphere, 
by suspending from their necks bits of camphor loosely tied up in a 
rag. Both children recovered; whether this camphor-atmosphere 
contributed any thing thereto, more extensive trials may deter- 
mine. 

(b.) Paralysis Glottidis. — Paralysis of the glottis is a rare affec- 
tion. This may appear remarkable, since tumors grow so frequently 
about the neck, and are liable to exercise pressure upon the vagus 
and recurrent laryngeal nerves, and thus produce paralysis of the 
laryngeal muscles. In vivisections after division of the recurrent 
laryngeal nerves, the glottis is seen neither to dilate during inspira- 
tion nor to contract during expiration ; but in a very deep inspiration 
it mechanically becomes narrowed or closed, as the strong current of 
air gives to the chordae vocales the form of two segments of a wheel, 
and their borders are thereby made to approximate, or even to touch 
each other, and thus be converted into valves. Paralysis of the 
glottis, resulting from disease of the central nervous system, is ob- 
served in most of the dying, and in very rare instances may also be 
caused by tumors, by large tubercles, or by carcinoma, existing 
at the base of the brain, a long time before death. Peripheral 
paralysis of the glottis originates through pressure upon the cervical 
portion of the pneumogastric, or upon the recurrent laryngeal nerve, 
which alone, according to the united investigations of Volkmann^ 
Longet^ etc., may give rise to dilatation, as well as to closure of 
the glottis. The pressure, as a rule, is caused by scrofulous en- 
largement of the lymphatic glands, lying in the course of the vagus, 
in which, at the autopsy, this and the recurrent nerves are found em- 
bedded and flattened. This fact furnishes a means of explaining the 
\dolent paroxysms of dyspnoea that sometimes occur in scrofulous chil- 
dren, in whom the external glandular swellings are often so insignifi- 
cant that a dyspnoea, induced by their pressure directly, is altogether 
out of the question. 

Symptoms. — The principal symptom is an uninterrupted, labored, 
rattling respiration, which, at every deep inspiration induced by 
crying, laughing, and strong exertions, terminates in a paroxysm of 
cough. 

The respiratory sound is as loud as in croup, but is distinguished 
from croupy breathing by the less shrill and more rattling tone, and, 
in addition, by the ordinarily very shght dyspnoea, which, however, 
during the cough-paroxysms becomes more marked, and is often 
aggravated into an orthopnoea. This condition is always chronic, and, 
when no other afflictions are accidentally present, not attended by 



DISEASES OF THE RESPIRATOKY ORGANS. 2Y9 

fever. The voice here is rough, hoarse, and even complete aphonia 
may exist. 

The duration of this affection cannot be foretold. On one occasion 
I saw it disappear spontaneously, although the glandular swelling 
visibly increased in size. It is presumed that a softening or absorp- 
tion of the deeper portions of the gland took place, and thus re- 
lieved the pressure. Generally, the prognosis is unfavorable, a 
diffused bronchitis soon supervenes, and not unfrequently pulmonary 
tuberculosis, which in a short time carry off the patient. 

Treatment. — As scrofula is almost always at the bottom of this 
affection, an antiscrofulous treatment will, therefore, be absolutely 
indicated. Cod-liver oil is decidedly the best remedy for it ; locally, 
painting with iodine, repeated two or three times every week, most 
rapidly effects a diminution of the glands. If, in this manner, we do 
not succeed in removing or at least in mitigating the evil in from eight 
to fourteen days, it will be absolutely necessary to extirpate the affected 
glands. The effects which the hypertrophied glands produce show 
conclusively that they extend deeply down, and this operation should, 
therefore, only be undertaken by a skilful operator, well versed in the 
anatomy of the parts. 

C^.— THYROID GLAND. 

If we exclude the extraordinarily rare thyroiditis inflammatoria, 
and traumatica, which may occur as the effects of external injuries, such 
as from throttling, contusion, etc., there will only remain for consider- 
ation the various kinds of hj^ertrophy of the thyroid gland. 

Steixsia. — By struma we understand all kinds of enlargement of 
the thyroid gland. Sometimes the increase in size is only tran- 
sient ; generally, however, it is permanent, and constantly progresses. 
Either the whole gland hypertrophies, or only a single lobe or a 
small section of a lobe, and the symptoms of compression vary ac- 
cording to the direction in which the enlargement progresses. 
When the gland enlarges outwardly and anteriorly, the integument 
covering it will become gradually distended, and, with the exception 
of the unsightly disfigurement, no further disturbance of the functions 
of the adjacent organs will ensue. But if it becomes enlarged back- 
wardly and laterally, the sterno-cleido-mastoidei muscle and the large 
vessels and nerves of the neck will be displaced, and manifold disturb- 
ances of the circulation and innervation supervene. With these, seri- 
ous embarrassments of deglutition and of respiration become asso- 
ciated. When, for example, and fortunately very rarely, it happens 
that the strumous gland surrounds the oesophagus and trachea like a 



280 DISEASES OF CHILDREN. 

ring, the symptoms assume a very serious aspect ; and when the lower 
border of the gland enlarges in leng-th, growing downward beneath 
the manubrium sterni, it hypertrophies in every direction. 

The enlargement of the gland takes place in two ways. Either 
the gTanules or cells of the normal gland become developed in greater 
numbers, and thus produce a perfectly normal glandular substance, but 
hypertrophied in volume (struma lymphatica), or a few thyroideal 
granules become enlarged into extensive cysts, which even in children 
a few years old may attain to a diameter of one inch and more (struma 
cystica). The contents of these cysts are a semi-consistent, gluey, yel- 
low, or brown liquid, for which the name of colloid has been in- 
vented. In goitre of children the w^alls of the cyst are invariably 
attenuated and soft, while in older individuals they are well known to 
be markedly thickened, and have even been found to have under- 
gone ossification. The cystic goitre has a nodular and uneven feel ; 
large cysts fluctuate distinctly ; lymphatic goitres never display 
any globular distention, and have a uniform consistence in every di- 
rection. 

Infants occasionally come into the world with congenital lym23hatic 
struma, they are liable to be semi-asphyxiated, and are only with 
the greatest difficulty brought to life, and, even after that, they breathe 
loud and laboriously. This goitre of the new-born child disappears 
spontaneously in a remarkable manner after several weeks. Usually, 
however, older children, girls particularly often, are affected by it after 
commencing the second dentition, and here the lymphatic struma is 
as frequently met with as the cystic. In children the above-mentioned 
serious symptoms from displacement of and pressure upon the organs 
of the neck, and of compression of the trachea beneath the sternum, 
are, on the whole, extremely rare ; usually medical assistance is only 
sought on account of the unsightly appearance. 

Treatment. — Surgical interference, on account of the dangers at- 
tending upon the extirpation of goitres, and even upon simple punc- 
tures and injection of the cysts, is only admissible when the symptoms 
are of the most urgent kind ; no operative procedure should be under- 
taken solely on account of the disfigurement. Lymphatic struma 
uniformly disappears under the external use of iodine repeated six to 
twelve times, at from three to six days' intervals. Cystic goitre does 
not disappear under this treatment, but becomes visibly smaller, or at 
any rate does not grow larger, so that, with the increasing size of the 
body, the deformity becomes less striking. Tincture of iodine acts 
remarkably quick and surer than the compound iodine ointment, and 
on that account I never use the latter. 



DISEASES OF THE RESPIRATORY ORGANS. 281 



jy.—TRYMU8 GLAND. 

As the anatomy and physiology of the thymus gland have already 
been discussed on page 3, there only remain to be mentioned the 
few pathological appearances which in rare instances occur in it. 

As regards asthma thymicum, it has already been stated, in the 
section on sjKtsmus glotticUs^ that the size and position of the thymus 
gland probably have no influence whatever upon the spasms of the 
glottis, for in many autopsies the gland has often been found large, and 
then again small. But the name asthma thymicum Koppii is doubly 
incorrect : (1), because the thymus has nothing to do with the asthma ; 
and (^), because long before Kopp^ who published his work in 1829, 
the greatest authorities, such as Morgagni^ P. FranJc^ Allan JBurns, 
etc., sought to establish the view that the thymus may produce suffo- 
cative attacks. 

In new-born and in still-born children F. Weber found small hgemor- 
rhages into the parenchyma of the thymus. They have been observed 
singly and in multitudes, associated with intense hyperaemia of the 
entire organ, and generally do not attain to a size larger than a pin's 
head. Usually ecchymoses are also found in the other organs. Weber 
attributes all these extravasations to the act of delivery ^^e?' se, and states 
that they are only absent in rare cases, as, for example, where a small 
child was delivered from a large pelvis dead, from any cause which 
could not be ascribed to the circumstances of pressure. 

Tuberculosis of the gland not infrequently occurs ; and even the 
large genuine tuberculous masses, which generally have their site in 
the bronchial glands, have been seen in the thymus gland, while the 
former w^ere free. 

I have twice found carcinoma of the mediastinum anticum in boys 
five or six years old, the lungs, in both cases, being but very little 
implicated ; the pleurae and pericardium were also free, and therefore 
it appeared most probable that the disease originated from the thymus 
gland. 

Affections of the thymus gland, with the exception of carcinoma 
of the mediastinum anticum, which may be detected by extensive 
dulness over the anterior half of the chest, and manifests itself 
by pressure upon the heart, large blood-vessels, and the lungs, can- 
not be diagnosticated ; for the mere existence of dulness on per- 
cussion in the region of the sternum by no means allows a conclu- 
sion to be formed as to the state of the gland. For these anatomo- 
pathological alterations, the symptoms of which are so obscure during 
Hfe as to preclude a diagnosis, no treatment, of course, can be pre- 
scribed. 



282 DISEASES OF CHILDREN. 



-E.—ZaJH-GS. 



(1.) Bkok'chial Cataerh ( CataiYhus JBroyicMalis Acutus^ Chroni- 
cus). bronchitis. — In the physiological condition all mucous mem- 
branes are covered with a certain amount of secretion, essential to the 
functions of mucous membranes. Now, the bronchial mucous mem- 
brane likewise secretes a certain quantity of mucus, and in fact just as 
much as will suffice to prevent its becoming dry. Every hyperaemia 
of the membrane causes an augmentation of the secretion ; more is 
poured out than can be evaporated, and the consequence of this is an 
accumulation of mucus in the bronchi, which condition has been de- 
nominated bronchial, catarrh, or, in severer forms, bronchitis. 

Pathological Anatomy. — Bronchial catarrh may occur either in the 
bronchi of the first and second order alone, the smaller remaining un- 
affected, or conversely ; the principal morbid alterations are found in 
these, while the large bronchi remain normal, or finally the bronchi 
of all orders may be uniformly affected. Both lungs are seldom at- 
tacked simultaneously, a fact more particularly marked in t^^hus and 
the exanthematous fevers, and seldom only is the catarrh equally in- 
tensely developed throughout the bronchi of a lung. Generally, the 
secretion is most profuse in the lower lobes, and the morbid altera- 
tions of the mucous membrane more marked than at the apices of the 
lungs ; this is probably due to purely mechanical circumstances, the 
greater part of the secretion of the upper lobes descending by its own 
vf eight into the principal bronchi, while it can only be removed from 
the lower lobes by the action of the cilise, and by violent expirations 
and coughing. 

The affected portion of the mucous membrane is of a pink-red 
color, where the inflammation has attained a high grade. Its vessels 
present an arborescent injected appearance, and this injection increases 
more and more, and finally in the highest grade becomes so intense 
that the mucous membrane assumes a scarlet-red, velvety appearance. 
At the same time it increases in thickness, as may be ascertained witli 
the greatest ease by making a few transverse incisions into it, and by 
comparing the incisions of a normal bronchus with those of a catar- 
rhal bronchus, both being of the same order. In, addition the mucous 
membrane appears softened, is easily lacerated, and cannot be puUed 
off in patches from the submucous tissue. 

But the inflammatory redness should be strictly distinguished from 
the redness of imbibition, which is found in all cadavers after 
putrefaction has begun. In morbilli, it is claimed that sometimes the 
bronchial mucous membrane is covered with the same spots as the 
integument ; in small-pox, pustules are met with in the trachea and in 



DISEASES OF THE RESPIRATORY ORGANS. 283 

the bronclii of the first and second order. The erosions, which ac- 
company chronic bronchial catarrh of the adult, have never yet been 
found in children, even when they had a cough for many years. 

The secretion is sometimes frothy, and w^hitish, sometimes only 
permeated by a few air-bubbles, a semifluid, yellowish mass, filling 
up the whole calibre of a bronchus. !Microsco23ically, it is composed 
of a few characteristic epithehum-cells, most of which are seen to be 
oval without complete angles, and of pus-cells which here are unu- 
sually large, finely granular, and globular. In addition to these in- 
flammatory corpuscles, now and then entire pieces of softened mucous 
membrane are found. 

When a sHght pressure is exercised upon the incised catarrhal 
lung, a drop of this secretion will ooze out from every diseased bron- 
chus ; the number and size of the yellow dots thus produced in the red 
pulmonary parenchyma furnish a means of judging the extent and 
severity of the catarrh. I am unable to decide whether coagulge of 
fibrin also occur in tliis secretion, as some authors state, for I have 
never yet found them. It is remarkable that lungs thus affected do 
not collapse on opening the thorax, on account of the large quantities 
of the accumulated secretion, which prevent a communication betw^een 
the external air and that in the lungs. In chronic catarrhs, the 
bronchi become somewhat dilated, a condition caused by the super- 
vention of softening and atony of the mucous membrane. But the 
dilatation is always shght, cylindrical, and never cystic ; cystic bron- 
chiectasis never occurs in the infant. Li bronchial catarrh one portion 
or another of the pulmonary parenchyma sooner or later generally 
becomes affected in the form of lobar pneumonia, which will be 
specially described in the following section. 

Symptoms. — They are divisible into subjective and objective. 
The subjective only come into consideration in children who are more 
than two years old, and consist of pains along the sternum, to which, 
during cough, a girdle-like pain, corresponding in direction to the 
insertion of the diaphragm, becomes superadded, aild sometimes in a 
general malaise^ w^hich manifests itself by a depression of spirits, and 
disgust for the customary amusements. The objective symptoms are 
derived from physical exploration, from the kind of cough, the ex- 
pectoration, and the invariable fever. The cough is always the most 
striking symptom ; it alone causes the parents to seek medical assist- 
ance. Generally, the paroxysms of cough are tolerably severe, and 
last from half to one minute, recur several times in the hour, are less 
frequent during sleep, but do not cease completely. Many children 
sleep on, notwithstanding the cough ; others, however, always wake up, 
and from these constant interruptions in their night's rest become very 



284: DISEASES OF CHILDEEN. 

much reduced. The short, abrupt, frequently-recurring, hacking cough 
is very suspicious, for it usually points to the existence of tubercu- 
losis. A bad sign furthermore is, when the children cough more 
when laid on one or on the other side than on the back, for this 
cough too, in most cases, is due to great material alterations in the 
pulmonary structure. Children with simple bronchitis cough less in 
the dorsal decubitus than in the upright posture ; no difference can be 
noted in them between the dorsal and the lateral decubitus. Nor 
is the pain so severe as to cause them to distort the face when 
coughing, or to give other manifestations of pain after the cough has 
ceased. 

The expectoration, so important in adults, enabling us to judge of 
the condition of the lungs, is very seldom seen in children. By the 
sound of the cough it is, indeed, perceived whether any mucus is or is 
not propelled out of the larynx, but, from the hawkings and the rotator}'- 
movements of the tongue of children from three to five years of age, 
we learn that they do not know as yet how to execute any other 
movement than to regularly swallow down again the sputum that has 
already reached the root of the tongue. Only when the paroxysms 
of cough are very violent, and the mouth is held wide open, is it pos- 
sible, occasionally, to see the sputa ; they may be often easily ob- 
tained, after a loose cough, by wiping the root of the tongue with a 
clean piece of rag, to which they will remain adherent. In bronchial 
catarrh, the sputa are either white and frothy or yellowish, and 
then, as a rule, less rich in air-bubbles. They are never colored 
bloody; still, as in every violent exertion, so also from coughing, 
small bleedings may take place from the larynx, fauces, and mouth, 
the blood of 's\'hich, however, is never uniformly mixed with the sputa, 
but always seen in clear single streaks, or in masses. In the majority 
of cases, the expression of the face, in simple bronchitis, is but little 
changed ; since, as a rule, no fever is present, the temperature of the 
head, therefore, also remains unaugmented, and no reddening of the 
cheeks is observable. But, if the bronchitis is very extensive, if the 
bronchi of all orders, in both lungs, are affected, then a very marked 
cyanosis supervenes, for which, when such a child is seen for the first 
time, a different cause is uselessly sought in the circulation. Such an 
extensive affection of the bronchi is extremely dangerous, the respi- 
ration is as labored as in pneumonia, and death ensues usually by suf- 
focation. In the dissection, the pulmonary parenchyma is only occa- 
sionally found perfectly normal; generally, lobular pneumonia has 
supervened in several places. 

The physical exploration of the lungs of small children has already 
been commented upon on page 18. All the cautions and deviations 



DISEASES OF THE RESPIRATORY ORGANS. 285 

from the examination of the adult were enumerated there, and will 
hare to be kept constantly in view in the following section on the 
various pulmonary affections. The examination of older children — 
those that are over five years of age — differs in no respect from that 
of the adult, but in children of from one to five years the possibility of 
such an undertaking depends entirely upon the conduct of the physi- 
cian. The main point always is, and always will be, to get on friendly 
terms with the child, and then only to commence the examination. 
If the child is immediately ordered to be undressed, and the percus- 
sion and auscultation undertaken without any further precaution, in 
ninety-nine cases in one hundred an uproarious cry will be set up, 
which will not cease till the cause has been altogether withdrawn — 
still more, it will always be set up again as soon as the physician, 
who has created such an impression, returns ; under which circum- 
stances the formation of a correct diagnosis and the institution of a 
rational treatment are, of course, altogether out of the question. 

Percussion in bronchial catarrh gives totally negative results; 
the tjTnpanitic percussion-sound generally is very marked, and the 
physiological dulness on the right side posteriorly, when the abdomi- 
nal organs are pressed upward, is, in small children, very marked 
during bronchitis, for the temporary blocking up of the air in the 
bronchi, by the accumulated masses of mucus within them, is very 
readily effected. 

Palpation is the most useful, and, at the same time, the simplest 
method of examination. In bronchial catarrh, mucus and sibilant 
rales are distinctly felt over the whole thorax, strongest, as a rule, 
over the larjmx and trachea, for here the largest mucus-bubbles 
burst, and single tenacious mucus-lamellae are kept in a state of 
vibration by the cm-rent of air up and down. If a conclusion were 
formed as to the extent of the catarrh, from the extent of surface over 
which these moist rales are felt, we would very often commit a serious 
error, for, as often as any rales, at all loud, form in the larynx, it will 
be easy to feel them over the whole thorax, and a few active coughs, 
which result in expelling the mucus from the larynx, frequently suffice 
to cause the rhonchi to disappear from the entire chest. Only when 
no rales are felt over the neck, but, on the contrary, are perceptible 
over one side, or over a circumscribed space, then they will not dis- 
appear after so short a time, but will be noticeable for weeks, and 
even months. If any great importance can be at all attached to the 
feeling of the rhonchi, then it is a less favorable sign when the}^ appear 
over a circumscribed spot tlian when they are diffused over the en- 



286 DISEASES OF CHILDREN. 

tire cliest, inasmuch, as, in the first case, the bronchitis has estab- 
lished itself in the bronchi of the third and fourth order, while in the 
second a single sputum in the trachea, which will be coughed up in 
the next hour, may possibly be the cause. But if the rales which 
are diffused over the whole thorax are constantly felt for days, and 
even weeks, then it is a proof of the existence of the most extensive 
bronchitis, which is usually already combined with very considerable 
dyspncea. 

By auscultation w^e learn, in bronchial catarrh, little more than by 
palpation. By a little practice, the rhonchi may be felt just as well as 
heard ; it is even possible to distinguish the pitch and intensity, and, 
in addition to that, w^e have the advantage of being able to carry out 
the examination quicker, more accurately, and with less opposition on 
the part of the child, by palpation. Auscultation is desirable mostly 
because by it a complication with pneumonia, which is recognized by 
fine crepitation, and, later, by bronchial respiration, may be diagnosti- 
cated. I cannot participate in the views of some authors, who main- 
tain that fine crepitating rales are heard in bronchitis capillaris. By 
this hypothesis the last distinguishing mark between bronchitis and 
pneumonia would be lost, and the confusion, which is already suffi- 
ciently embarrassing without this, would thus become still greater. 
Where crepitating rales are heard in a child, simple catarrh of the 
small bronchi cannot be assumed to exist, but a pneumonic, alveolar 
disease. The presence of rhonchi of various kinds, and of rough 
vesicular breathing, answers for bronchial catarrh and bronchitis; 
crepitating rales and, still less, bronchial breathing, ought never to 
occur in this condition. 

The respiration in children with ordinary bronchitis does not de- 
viate from that of the physiological state, but, when the affection is 
very extensive, the respirations become more frequent and laborious ; 
but, as fever generally is superadded, and also accelerates the respira- 
tion, it is difficult to determine how much of the frequency of the 
respiration should be ascribed to the catarrh, and how much to the 
fever. The movements of the alae nasi, which accompany every act 
of respiration, are very rare in bronchitis, and, almost without excep- 
tion, indicate a complication with pneumonia. 

The duration of this disease varies exceedingly, according to the 
cause and the constitution of the child. A child that is not pre- 
disposed to catarrhs may contract a cough through external irritation, 
such as cooling of the thorax, too cold air, injurious and impure at- 
mosphere; but it hardly ever lasts long, and disappears in a few 
days. On the other hand, there are children w^ho, without being 



DISEASES OF THE RESPIRATORY ORGANS. 287 

rhx3 progeny of tuberculous parents, suffer for years, with only sliort 
remissions, from bronchial catarrhs ; and, lastly, we have the actually 
tuberculous, who very seldom get rid of it. The prognosis is not 
always to be given as favorably as we should be inclined to assume 
from the general well-being of the child. The simplest bronchitis, 
when it becomes greatly diffused, may eventuate in death by suffo- 
cation ; that founded upon tuberculosis, of course, offers but a very 
unfavorable prognosis. 

Etiology. — There is hardly a child living who has not had a bron- 
chial catarrh in early life, and there is no age at which this affection 
occurs oftener than in that of the first childhood, particularly at the 
time of the first dentition. Thus, for instance, all children cough who 
drivel during dentition, for the garments are perpetually kept wet by 
the saliva, and that produces a cooling of the chest. Bronchial 
catarrh prevails more generally in winter than in summer, in the 
cities and quarters inhabited by the poor, more frequently than in the 
country. Children reared in dusty manufacturing cities usually suffer, 
and children of tuberculous parents so regularly suffer from it that it 
does not at all attract attention, and therefore is not mentioned, if 
special inquiry be not made concerning it. Besides these more 
external causes, there is also a contagion which conveys the bronchial 
catarrh from one person to another, namely, influenza (die Grippe). 
Essentially it consists of a bronchial catarrh, which is ushered in by 
febrile symptoms and anorexia, and spares no age, not even the 
youngest infant. In healthy children, influenza has its regular 
course, and, in from two to three weeks, terminates in complete re- 
covery ; in tuberculous children, on the contrary, it often ushers in 
the further development of the cachexia, the children continue to 
cough, become feverish, and finally perish in a hectic condition. 

Bronchitis, furthermore, occurs as a complication in a number of 
general diseases. Thus the bronchial membrane, like the intestinal 
mucous membrane, is implicated in every typhus fever, and, in mild 
cases of febris typhodes, this constant symptom is the most impor- 
tant one in confirming the diagnosis. 

Rohitansky is even of the opinion that bronchitis (bronchostasis) 
forms the foundation of the exanthematous contagious typhodes, 
such, for example, as occur in Ireland. 

The more detailed views concerning this condition have akeady 
been given on page 185, in connection with typhus abdominalis. 

Bronchitis, lastly, is a constant symptom in measles, where it prob- 
ably originates through a morbillous efflorescence of the mucous mem- 
brane, and hence must occur without any exception. It is frequently 
met with in scarlatina, and in both genuine and spurious variola. 



288 ' DISEASES OF CHILDREN. 

Treatment. — There is no remedy that has a marked direct influ- 
ence upon the course of bronchitis. All the methods of treatment 
hitherto recommended are frequently found to fail. There are prin- 
cipally two symptoms, for the subjugation of which every effort 
should be made, namely, the dyspnoea, and the immoderate secretion. 
The first originates through the accumulation of the bronchial mucus, 
with the removal of which it also disappears, and the best means for 
effecting this is the act of vomiting. It is not necessary to give 
strong emetics, for, by these, vomiting is produced too rapidly, and 
the retchings, which in reality are the most important results, by no 
means stand in direct relation to the size of the dose. A very good 
means of inducing protracted retching and vomiting consists in the 
administration of a strong infusion of ipecacuanha ( 3 j to water 3 j), 
of which even one teaspoonful has the strongest effect without impli- 
cating the ahmentary canal. If, during and after vomiting, no large 
quantities of mucus 'are expelled, and if the breathing does not 
thereby become easier, any further emesis will prove useless, and 
will only give rise to a chronic gastric catarrh, by which the child is 
very much reduced. As to the class of expectorants, the vegetable 
ones only are recommendable, and even these should only be used 
in cases where no disturbance of the digestion exists. When the 
latter supervenes, the harm caused by the expectorants is more ap- 
parent than their very problematical usefulness, and this remark is 
especially applicable to the antimonials, tartar emetic^ sulphuret of 
antimony^ Jcermes-mineral^ and white oxide of antimony. Muriate 
of ammonia, so much in vogue in bronchitis of the adult, usually is 
not administrable to children in any form. In acute catarrh of the 
bronchi of infants, a mild infusion of ipecacuanha (gr. j to water 3 j), 
with a little oxymel simplex^ or a very dilute solution of 'kali carh. 
(gr. ij — 3 j) are the most appropriate remedies. Little very highly 
recommends frictions of the chest with turpentine every two or three 
hours, and covering of the chest with flannel. When the paroxysms 
become spastic, antispasmodics and narcotics are indicated, which not 
only exercise a favorable abortive effect upon the severity of the 
cough, but also upon the course of the disease generally. Chief 
among these is aq. amygdal. amar.^ given in two or three times as 
many drops pro dosi as the child numbers years of age, three or four 
such doses daily ; next laudanum, in doses already mentioned, several 
times ; ext. belladonna, gr. -^ to -j^, several times daily, etc. 

When tuberculosis is at the bottom of the catarrh, this treatment 
of symptoms, as a rule, proves entirely fruitless. In these cases 
ol. jecor. iron and qidnine must be tried. Pulv. cinchona, given in 
quantities such as can be taken up on the point of a knife, can be 



DISEASES OF THE RESPIRATORY ORGANS. . 289 

administered to almost all cliildren, and I have frequently seen very 
suspicious bronchitis, accompanied by febrile exacerbations and ema- 
ciation, disappear under a continuous employment of this remedy for 
from four to eight weeks. The temperature of the room in which the 
little patient is confined should be uniformly warm, the garments 
warmer than those worn in health ; the drinks should be plentiful, so 
that a beneficial perspiration may be established. If the cause of 
the catarrh still continues, its removal, of course, must be attended 
to ; it should be particularly insisted upon not to allow the children to 
remain in dusty manufacturing cities, as is so often the case with the 
laboring classes. 

In order to guard against further bronchial catarrhs, and to coun- 
teract the disposition to that disease, a systematic inuring is to be 
urgently recommended. As regards the clothing, no definite direc- 
tions can be given; at any rate the garments should not be so warm 
as to make the children feel uncomfortable, and cause them to per- 
spire profusely on taking a little exercise. More catarrhs are un- 
doubtedly produced by these warm dressings than prevented. The 
best and most rational means of inuring is to sponge the whole body 
with cold water before the child retires for the night ; this may be 
commenced with immediately after the eruption of the canine teeth. 

(2.) Lobular axd Lobar Inflammation op the Lungs 
(PneumjOnia Xiohularis et Loharis). — Pneumonia occurs extremely 
frequently in children, generally, however, in a form which anatomo- 
pathologically presents a different picture from that which we 
are in the habit of finding in the autopsies of adults. Namely, 
the lungs do not become extensively inflamed, throughout one or 
more lobes, but only in some places scarcely of the size of peas, 
between which normal pulmonary tissue is found in tolerable quan- 
tities, a process that has been correctly described as lobular pneumo- 
nia. Lobar pneumonia, it is true, also occurs, but comparatively 
much less frequently ; it may come on idiopathically, or be produced 
by a blow, as in the adult; usually, however, it is like pleuritis 
of the new-born child, of a pyj^mic nature. In the latter case it al- 
ways terminates fatally ; the prognosis, on the whole, even in lobar 
pneumonia, not of a pysemic character, is also extremely unfavorable. 
In the nursling, lobular pneumonia is an extremely frequent affection, 
and carries off many children, especially during the period of dentition. 
In foundhng-hospitals many children die from it, and the horizontal 
posture in which these children are kept both night and day has 
been considered the chief cause. What tends to confirm this view is 
the circumstance that, in most of the autopsies, the posterior and low- 
est portions of the lungs, and consequently the most depending parts, 
19 



290 . DISEASES OF CHILDREN. 

have been found oftenest affected. Moreover, it has been statistically 
demonstrated that many more children su^er from it in winter than in 
summer, and that a part of the lung is never found with lobular in- 
flammation to which the bronchi leading to it do not also exhibit a con- 
siderable degree of catarrh. The relation of lobular pneumonia to bron- 
chial catarrh is probably of such a character that the gravitating se- 
cretion acts as an irritant, and perhaps mechanically upon the region 
in which the affected bronchi terminate, and that at the irritated 
places small pneumonia3 develop themselves secondarily. We have 
here, therefore, the relation of cause to effect. This condition also 
arises in most cases of croup, and lobar pneumonia is about as fre- 
quent here as lobular pneumonia, and the extension of the false mem- 
branes — whether they are thick or thin, confined to small or large 
surfaces, or extend far down into the bronchial tube on all sides — ^has 
no particular influence upon the origin of pneumonia. It is also found 
in almost all the cadavers of children who have succumbed to sclerema, 
and often it supervenes as the closing scene in tuberculous lungs. 

Pathological Anatomy. — The anatomo-pathological processes are, 
as the names already designate, of two kinds, and lobular pneumonia 
is distinguished from lobar, not only as regards the extent but also as 
regards the quality of the exudation. 

Lobar pneumonia^ with the exception of the metastato-pygemic 
form, occurring in lying-in and foundling-hospitals, is remarkably rare 
in the nursling, but wherever it does occur it displays the same morbid 
alterations as in the adult. Here also we have a red and gray hepa- 
tization, according to the time of the occurrence of death. The exuda- 
tion is not poured out between the pulmonary alveoli nor into their 
walls, but into the cavities themselves, filHng them up completely, and 
having the properties of purely croupous exudation. The red hepatized 
lung does not collapse on opening the thorax, it is totally emptied of 
air, the cut surfaces are dry and brownish red, mostly uniformly granu- 
lar, and such portions of the lungs are as friable as the parenchyma of 
the liver. The granular quality of the section is produced by the elas- 
tic fibres lying between the alveoli, which are swollen by the deposit 
of firm exudation. The red color of the exudation is due to the inter- 
spersion of blood-corpuscles. 

The exudation, which, with the exception of the blood-corpuscles, 
primarily was amorphous, becomes quickly transformed into albumi- 
nous and muculent masses ; cells soon begin to form, which are produced 
alike from the alveolar walls and from the exudation. The blood-cor- 
puscles meanwhile are undergoing dissolution, their coloring matter 
disappears, the entire mass changes its color, grows pale — gray hepa- 
tization — and the exudation constantly grows more like J3us, on accoimt 



DISEASES OF THE EESPIRATORY ORGANS. 291 

of which the French physicians have also called it infiltration purulente. 
Finally, the contents of the alveoli dissolve to a milk-like consistency, 
and are immediately absorbed, and then the rather rare process of a 
complete restitutio in integrum occurs. Occasionally large abscesses 
form, and still more rarely complete obsolescence, hardening, and in- 
duration, of the pulmonary tissue take place. In children lobar pneu- 
monia never degenerates into tuberculous, as sometimes occurs in the 
adult, for tuberculous children generally succumb in the first few days 
after having acquired the croupous pneumonia. 

Lobular pneumonia \s, w^oi a croupous, but a catarrhal inflamma- 
tion. Here small spots in the healthy pulmonary parenchyma become 
diseased, which, although they sometimes aggregate, nevertheless do 
not present the morbid appearance of the croupous lobar pneumonia. 
Generally, the disease involves both lungs, the right more than the 
left, and the posterior parts of the lower lobes are oftenest afi*ected. 
Such lungs do not collapse completely, and this is not due so much to 
the lobular pneumonia as to the bronchial catarrh that constantly ac- 
companies it, and when they are felt in different directions a few hard 
nodules will be found near their surface or deeply within them. If 
these nodules are now divided, bluish-red, denser spots, without sharp 
circumscriptions, will be seen in the transverse section. The walls of 
the pulmonary air-cells are intensely swollen, and, when they are 
scraped with the scalpel, a reddish, muculent, but sparsely-frothy secre- 
tion is obtained. The lobules affected with pneumonia seem to be 
somewhat beneath the level of the surface, on account of the pulmo- 
nary tissue surrounding them being mostly emphysematous, and their 
darker color makes them easily recognizable. If such places are care- 
fully cut out, so that no normal pulmonary substance remains attached 
to them, they will sink completely in water, and do not present the 
least trace of crepitation. But, by inflating the whole lung, they again 
become filled with air to a certain extent, in contradistinction to the 
croupous pneumonia, in which inflation has no effect whatever ; still 
these inflated lobules always retain a darker-red color, and a percep- 
tible hardness. The microscopical examination shows that the pulmo- 
nary vesicles are filled with large quantities of newly-formed epithelium- 
cells and fluid exudation. We have here, therefore, no red and no 
gray, in fact, no hepatization whatever, for which a firm, solid exuda- 
tion is always necessary, and hence also no different stages. Even 
when lobular pneumoniae become confluent, the lobules are neverthe- 
less distinguishable from croupous lobar pneumonia, by the absence of 
friability, by the possibility of forcing air into them by inflation, by 
the greater moistness, and by the remaining free parts which at all 
times are interspersed between those affected. The process always 



292 DISEASES OF CHILDREN. 

remains catarrhal, never becomes of a croupous nature. When pneu- 
monia is superficially located, we find in addition exudations upon the 
pleura, and invariably bronchitis in the bronchi leading to the inflamed 
places. The secretion in the arachnoid sac of the medulla spinalis is 
said to be augmented. The most common complications are thrush, 
enteritis folliculosa, and sclerema. 

Symptoms. — The symptoms of lobular and lobar pneumonia may 
be very properly described together, since all the signs, with the ex- 
ception of one, furnished by percussion, differ but little from each 
other. In the following description, children under two years are re- 
ferred to : children who have passed the first dentition seldom suffer 
from lobular pneumonia. They usually have lobar pneumonia, which 
differs in no respect from that of the adult. The physical diagnosis of 
infantile pneumonia is attended by great difficulties, and requires much 
patience and time. The children are invariably opposed to the exami- 
nation, and set up such a cry as to render all investigation impossible. 
Added to that, the sputa are also entirely absent, and by their very 
absence demonstrate their importance in the confirmation of the diag- 
nosis. For this deficiency, however, we are indemnified by the char- 
acteristic appearance of the child, and a very peculiar kind of respira- 
tion, whose presence is so characteristic that with a little practice it is 
possible to diagnosticate such an infantile pneumonia even before the 
child is undressed. 

It is seldom possible to accurately establish the commencement of 
a lobular pneumonia, for a bronchial catarrh always precedes it for 
some time, and its transition into pneumonia does not take place at 
once. It is generally ushered in by a cough, without fever, which 
grows worse and worse ; sooner or later fever supervenes, the tempera- 
ture of the skin constantly rising higher, and in a few days the whole 
train of symptoms of pneumonia is fully developed. 

The most striking symptom is great acceleration of the breathing, 
which may rise to sixty and eighty per minute, and have an inverse 
rhythm. While in health the accent lies upon the inspiration — if the 
respiratory sounds be at all audible — in pneumonia, the accent falls upon 
the expiration, which is accompanied by a louder noise than the inspi- 
ration. The most energetic contractions of the diaphragm are now 
seen. At every respiratory act the intercostal spaces sink, producing 
a momentary depression beneath the nipples, extending toward the 
sternum. In a higher grade of pneumonia, the facial muscles also 
participate, the alse nasi rise — a phenomenon upon which too much at- 
tention cannot be bestowed — the mouth is opened, the angles of the 
mouth are drawn downward and outward, indicative of suffering, and 
the eyes glassy, staring, or anxiously rolling about. 



DISEASES OF THE RESPIRATORY ORGANS. 293 

These symptoms of the respiratory modus, and the facial muscles, 
are not more pregnant with information than are the results derived 
from the physical examination fruitless. 

Percussion gives a purely negative result in lobular pneumonia ; 
in the lobar form, marked dulness is found over the inflamed places — a 
dulness which, in contradistinction to the physiological dulness during 
abdominal pressure, may be demonstrable without percussion, both 
during the inspiration and the expiration. That this physiological dul- 
ness posteriorly on the right is very frequently confounded with the 
pneumonic dulness is but too evident, from the fact that it is expressly 
stated in all the text-books that croupous pneumonia establishes itself 
by preference in the right lower lobes. 

Also the rapid and generally favorable course that is ascribed to 
and claimed for pneumonia in the yearly reports of children's hospitals 
and nurseries, shows tolerably plainly that the error is of frequent 
occurrence. 

The rest of the precautions that are to be observed in percussion 
have already been stated in the general part, page 20. 

By auscultation^ fine crepitating rales may be detected in lobular 
pneumonia ; but by this we do not intend to say that no pneumonia 
exists wherever these are absent, for the dense places which give rise 
to them do not always lie near the periphery. Added to that, bron- 
chial catarrh is always present, the sonorous rales of which often mask 
the much less audible crepitations, and the latter are also inaudible 
when the afi'ected places are very much scattered between large por- 
tions of healthy parenchyma. As they are usually perceived within a 
small circumference only, a very close examination of the entire dorsal 
surface is, therefore, necessary for this purpose, which, in restless chil- 
dren, or in those that have once been disquieted, is impossible, even 
with the utmost patience and perseverance. Sibilant rales are in- 
variably heard over both lungs. Crepitating rales is a valuable sign 
in confirming the diagnosis ; their absence, however, does not exclude 
pneumonia. 

In lobar pneumonia, fine crepitation, as in the adult, is heard at 
first ; then, for several days, distinct bronchial breathing, strong con- 
sonance of the cough, of the voice and rhonchi, and, thereupon, crepita- 
tion again ; till finally, at the end of eight or nine days, in case of re- 
covery, normal vesicular respiration returns, if the still-existing bron- 
chial catarrh does not produce for some time difi'used sonorous rales. 

By palpation nothing but sonorous rales are felt in lobular pneu- 
monia ; the vibrations of the thorax, caused by coughing and crying, 
are alike on both sides. In lobar pneumonia, stronger vibrations of 
the cough, of the rhonchi, and of the voice, are felt over the parts cor- 



294 DISEASES OF CHILDREX. 

responding to the dulness, or they are not to be felt at all if the bron- 
chi leading to the solidified lung are momentarily occluded by mucus. 
Palliation of the thorax cannot be too zealously practised, for in 
the crying child it is the only means which can be employed with 
benefit. 

The cry of children suffering from pneumonia is characteristic : it is 
never very loud, and still less continuous ; it should rather be called 
abruptly-interrupted moans and groans. The cough is frequent and 
persistent in all cases ; when it becomes violent and paroxysmal, httle 
white foam appears between the lips, even in the youngest children ; 
generally, however, no expectoration whatever is to be seen. The 
cough is distinguished from that in bronchial catarrh by being appar- 
ently productive of pain, the children groaning pitifully after each 
paroxysm, and, at the same time, distorting the countenance m evidence 
of suffering. 

The general symptoms vary according to the extent of the disease 
and its complications. The fever of lobular pneumonia usually begins 
after protracted feverless vespertine bronchial catarrh, disappears in a 
few hours, only to return with greater frequency and violence, till 
finally it becomes continuous. The skin is felt to be hot and dry, but 
the feet are cold and difficult to be warmed. The pulse becomes un- 
commonly rapid, and may rise to two hundred beats per minute. 
That is the utmost limit which, by any practice, it is possible to 
count. 

In most cases of lobar pneumonia, the fever begins suddenly, even 
before the symptoms of disturbed respiration become apparent, and is 
as severe as in the eruption of an acute exanthema. On the following 
day the pneumonia comes on, and assumes its cyclical course. The 
consecutive cerebral symptoms do not depend upon the extent of the 
pulmonary affection, but upon the individual irritability. There are 
children who, in the most violent lobar pneumoniae, retain a free sen- 
sorium, and others, again, who in the slightest ailment are attacked by 
all sorts of convulsion^ and nervous phenomena. 

There is complete loss of appetite, the thirst is great, and the 
secretion of urine corresponds to the amount of hquids drank. The 
stool is frequently diarrhoeal, because the majority of those affected 
with pneumonia suffer from the effects of dentition, and these, as a 
rule, are attended by loose stools. As this is often a result of the 
treatment, the impropriety of such treatment will be discussed more 
in detail in the future. 

The course is extremely rapid in lobar pneumonia, for death or im- 
provement ensues in from six to eight days. In young children the 



DISEASES OF THE RESPIRATORY ORGANS. 295 

fatal terniination is more frequent than recovery. Children over two 
years of age bear lobar pneumonia as well as adults. It is diiScult to 
determine the commencement of a lobular pneumonia, on account of its 
gradual development from a simple bronchitis, which must have pre- 
ceded for at least four or five days, but may have existed for weeks 
and even months. Its course is by no means cyclical, sometimes 
rapid, and attended by such pronounced symptoms, that every lay 
person is able to recognize an alteration in the lungs, sometimes so 
gradual and insidious that it escapes the most experienced diagnosti- 
cian. Such children seldom recover completely in less than two or 
three weeks, but, when it tends to a fatal termination, all the symp- 
toms become aggravated, the dyspnoea and the frequency of the pulse 
increase, the extremities become cool, the nails cyanotic, the facial 
muscles distorted more and more, and now the expirations are not par- 
ticularly accentuated. Finally, the respirations grow more infrequent, 
become gurgling or gasping, and death takes place by convulsions. 
In lobular pneumonia, which seldom occurs before the second or third 
week, JBouchut lost thirty-three out of fifty-five patients, ranging 
from a few days to two years of age. According to Valleix, all the 
new-born children in the Parisian foundling-hospital attacked by this 
disease die (out of one hundred and twenty-eight children one hundred 
and twenty-seven died). Trousseau has described, as a most unfavor- 
able prognostic sign, the swelling of the veins of the back of the hand. 
This sign is significant, in view of the fact that the cutaneous veins can 
only be seen in emaciated children, and that these children rarely re- 
cover from pneumonia. In robust children who perished by this dis- 
ease, I never observed any swelling of the veins of the hands during 
its entire course. 

Treatment. — Since every pneumonia is preceded by a bronchial 
catarrh, it is evident that in young children it ought never, under any 
circumstances, to be slighted. Those measures recommended in the 
previous section are immediately to be resorted to. The patients 
should be kept in a uniform temperature ; should not, even in summer, 
unless the air is perfectly still, be carried out of the room ; and should 
be kept warm and dry, especially about the chest. Internally, small 
doses of opium, belladonna, or aq. laurocerasi, are very appropriately 
given. This treatment, with strict surveillance, must be continued 
until the last traces of cough have disappeared. Whoever has treated 
many children with lobular pneumonia, and has seen the much-praised 
remedies disappoint expectations, will not regard this minute and 
careful prophylactic treatment of a simple bronchial catarrh as jDedan- 
tic and over-anxious. It is necessary to become habituated to regard 
the bronchial catarrh of every teething child as the possible beginning 



296 DISEASES OF CHILDREN. 

of a pneumonia,. Too often, unhappily, experience will prove that this 
view is a perfectly justifiable one. 

Abstraction of blood is still pretty generally recommended in both 
lobar and lobular pneumonia, when already fully developed, and 
leeches are resorted to for that purpose with especial preference, for 
cupping is too painful, and, on the small surfaces of the thorax, their 
application is rendered difficult. Phlebotomy is usually impracticable, 
on account of the smallness of the cutaneous veins and the density of 
the subcutaneous fascia. Two or three leeches are therefore applied 
around the nipple, upon the sternum, or, according to JBouchut^ on 
the inner surface of the thigh ; the subsequent haemorrhage to be 
encouraged for an hour. For the last five years I have not employed 
them at all, and must confess that, since then, I am more satisfied 
with the results of my treatment. I have frequently had opportunities, 
in consultation, of observing children in whom leeches had been em- 
ployed by physicians differing from my views in regard to the ab- 
straction of blood, and can report nothing favorable whatever of the 
course of pneumonia treated in that manner. Most of the children 
were prostrated and anaemic, the lips were blanched and eyelids pale, 
and, although temporary mitigation of their dyspnoea was said to 
have resulted, no such improvement was to be seen on the second day 
after. This treatment can be regarded as abortive in no other sense 
than that these children die sooner than those treated on the ex- 
pectant principle. When this treatment is followed by recovery, con- 
valescence lasts very decidedly longer, they retain their pale color 
and anaemic appearance for a long time, and their development is 
much retarded. Therefore, since I have never yet seen any marked 
benefit, but, on the contrary, very lamentable effects, produced by 
leeches, it would be totally inexcusable on my part not openly and 
directly to protest against the practice of abstracting blood. 

And I may say the same of the much-lauded tartar emetic, which 
men, in other respects of sound judgment ( Valleix, for instance), extol. 
Intestinal catarrh, according to the most extensive ex23erience and ob- 
servation, is the most frequent complication of pneumonia, and all 
those remedies are therefore to be avoided which are liable to pro- 
duce it. The chief of these is tartar, stihiat.^ which, particularly in 
small doses, insufficient to induce vomiting, almost invariably produces 
a diarrhoea that is difficult to arrest. The injurious effect of this agent 
upon the intestinal canal is earlier and more surely manifest than its 
favorable antiphlogistic and expectant action. In this respect, even 
ipecacuanha, although much less frequently, may do harm, yet the 
diarrhoeas following it are of much shorter duration, less pernicious, 
and easily controlled by small doses of opium. In dyspnoea and suf- 



DISEASES OF THE RESPIRATORY ORGANS. 297 

focative attacks, a few teaspoonfuls of a strong infusion of ipecacu- 
anha ( 3 j to ^yater 3 j) act decidedly favorably, but even this should 
not be given more than once in twenty-four hours, at the utmost. 
Diarrhoea must be arrested immediately by small doses of laudanum, 
one drop pro dosis, for example. A weak infus. ipecac, (gr. j — ij to 
water 3 j) causes neither vomiting nor diarrhoea, and therefore, in this 
respect, is harmless ; but whether the expectoration of the catarrhal 
secretion is thereby materially facilitated is another question. It 
may be safely stated that the changes in the kind and severity of the 
cough following its administration are not very striking. 

^7hen the skin is burning hot, and no diarrhoea is present, I give 
one-eighth of a grain of calomel, four or five times daily, until green, 
semi-fluid stools ensue ; after that a simple mucilage of gum-arabic, 
with a little syrup simpl. and tr. opii gtt. j — ij, until constipation 
is produced. The infus. ipecac, is avoided as long as possible, but 
may be prepared and preserved in a cool place till required. In cases 
where the dyspnoea increases rapidly, a large quantity of bronchial 
mucus is often suddenly expelled by an energetic act of vomiting, and 
in this manner very apparent palliation is frequently obtained. In all 
cases, the local treatment consists in the application of a moist girdle, 
in the following manner : A diaper, or a large white pocket-handker- 
chief, is folded up hke a cravat ; the bandage thus obtained should 
be three or four fingers wide, and the whole length of the handker- 
chief. This is now dipped in tepid water, and wrung out so that the 
cloth does not drip, and then applied, like a girdle, around the chest 
of the child. A second cloth, double the size of the first, is folded up 
in the same manner like it, but which must be six to eight fingers 
broad, and then applied, dry and warm, over the first. It is very ad- 
visable to interpose a piece of gutta perchar between the dry and the 
wet girdle, by which, on the one hand, the moistness of the first cloth 
is preserved longer, while, on the other, the second does not become 
wet. If the water with which the fomentations are made is not too 
cold, the child will tolerate them very well, and, in a short time, a 
slight retardation in frequency and improvement of the respiration 
are indicated by less motion of the al £enasi. These tepid compresses 
should be continued for from four to six days, and it is not at all neces- 
sary, during the entire time, to remove the bandage ; the gutta percha 
is raised up a little, and a few teaspoonfuls of water are poured upon 
the girdle, or it is moistened with a sponge. The principal thing is not 
to allow a cooling of the skin by evaporation to take place. To secure 
this object, the dry cloth should properly overlap the moist one on all 
sides, and, as it is impossible to prevent the upper cloth from becoming 
wet, it should be changed several times during the day. I certainly 



298 DISEASES OF CHILDREN. 

have applied this girdle many hundreds of times, and have very often 
seen rapid improvement ensue ; nevertheless, it cannot be denied that 
the half of these children jDcrish notwithstanding. If cold compresses 
are applied to the children, as recommended by some authors, a cry 
of fright is the consequence ; the child is seized with a feeling of dread, 
the breathing is palpably accelerated, and does not subside until the 
cold water has become warm through the temperature of the skin. 
Hence it seems more rational to make the compresses warm at once, 
by using warm water, in order to avoid the temporary restlessness 
and discomfort to the child. 

(3.) Acquired Atelectasis of the LiJiNrGS. — Congenital atelec- 
tasis has already been treated of (on page 54) in connection with the 
diseases which are regarded as the immediate effects of the delivery ; 
it therefore only remains for us to speak of the acquired atelectasis. 
This affection has the most intimate connection with rachitis of the. 
thorax, and therefore mostly occurs in children between the ages of six 
months and three years. In many cases the augmentation in the den- 
sity of the pulmonary tissue and the final atelectasis are due to a marked 
curvature of the spine, to a distended pericardium, hypertrophied heart, 
to aneurisms or neoplasms. It is found most exquisitely marked in 
pleuritic exudations, where the lung is compressed to the thickness of 
a finger and correspondingly condensed. 

Pathological Anatomy. — The degrees of atelectasis vary exceed- 
ingly. A mere increase in the density may occur, which is recognized 
by the augmented consistency, but the compression may also attain to 
such a high degree as to cause a total obhteration of the alveoli, and 
the disappearance of the capillary vessels. At first these compressed 
and atelectic places contain blood and have a great similarity to muscle, 
on account of which this condition has been called carnification ; but, 
when it has existed for some time, they become bluish brown or gray, 
shrink up into a leathery rind, the pulmonary tissue cannot be recog- 
nized, and is converted into a fibro-cellular mass, which is gradually 
displaced by the slightly emphysematous surrounding parts, and ulti- 
mately disappears altogether. Such sohtary atelectic places are very 
rarely found, at least, in older children and adults. Sometimes it is still 
possible to inflate such atelectic places, if they are of but recent forma- 
tion \ generally, however, this experiment proves fruitless, for the alveoli 
have actually disappeared, and been replaced by a fibro-cellular mass. 

When the lesion is extensive, it will have a similar effect upon the 
circulation as pulmonary emphysema. The capillary circulation be- 
comes so impeded here, that a stasis takes place in the trunk of the 
pulmonary artery, producing dilatation of the right side of the heart, 
and finally venous stagnation and cyanosis. 



DISEASES OF THE RESPIRATORY ORGANS. 299 

The cause of acquired atelectasis is therefore chiefly to be sought in 
the rachitic thorax ; the latter, however, originates in the following 
manner : The inspiration is brought about by the contraction of the in- 
spiratory muscles, and a dilatation of the pulmonary vesicles is thereby 
produced. A momentary rarefaction of the air within them results, 
which helps to overcome the atmospheric pressure which is becoming 
stronger and stronger upon the thorax, aided by the elastic pulmonary 
tissue, which drags inwardly at every inspiration. The combined effects 
of these forces is an inward curving of the intercostal spaces, and, in 
lean persons, of the clavicular region also. I was once able to see 
this condition most strikingly displayed in a child in whom a rib 
was broken in two places by the shaft of a w^agon running against 
it. The fragment of the rib, one and a half inches in length, was 
kept in place by mere skin, and flapped in and out with every inspi- 
ration and expiration, like the valve of a bellows. If the bony ribs 
have lost their firmness by being deprived of some of the calcareous 
salts, they will also participate in the inward movement, which other- 
wise is only seen in the intercostal muscles, and thereby lose their 
external convex shape. Moreover, they also yield to the diaphragm, 
which, by the pressiu-e of the abdominal viscera, drags upon them so 
as to retard their longitudinal growth (producing rachitic shortening 
of the bones). By these various forces is finally produced a distorted, 
contracted, and misshapen thorax, the contents of which necessarily 
must suffer, more especially as, in consequence of the curving and re- 
tarded growth of the spinal column, it is also lessened in perpendicular 
dimension. 

Symptoms. — In consequence of the diminished number of pulmo- 
nary cells containing air, an acceleration of the respiration necessarily 
must result, if an interchange of gases corresponding to the bodily 
weight is to take place. The respirations, in fact, are quickened and 
executed with considerable exertion, the alae nasi thereby participat- 
ing. The application of the stethoscope to the rachitic thorax is at- 
tended by many difiiculties, for the button-like sternal ends of the ribs, 
and the concavities in the region of the nipples, render a perfect adap- 
tation of the instrument impossible. We almost always have to con- 
fine ourselves to an immediate auscultation of the back, and gen- 
erally hear sonorous rales in all parts, because the bronchi lead- 
ing to the atelectic portions are affected with catarrhal inflammation. 
Over the diseased places proper crepitating rales and bronchial breath- 
ing are heard, provided the sonorous rales do not drown all other 
sounds. But on the infantile thorax, and especially the rachitic, the 
vesicular, puerile breathing is so sharp, and the expiration so loud, 
that the distinction between puerile and bronchial breathing consists 



300 DISEASES OF CHILDREX. 

only in a fine modification of tlie sounds, and tlie utmost skill is requi- 
site to distinguisli ^ith certainty bet^Yeen the two. 

By percussion it is but rarely possible to demonstrate the atelectic 
places, for, in most cases, they are too small in extent, and very fre- 
quently border on the liver, where, by the incarceration of the borders 
of the lungs between the upper surface of the liver and the inwardly- 
curved ribs, a condensation of the tissue is produced. Besides, we 
must always take into consideration the physiological dulness during the 
abdominal pressure, the rachitic condensation of the scapular portion, 
and the similar condition from the curvature of the spinal column that 
very frequently occurs, before we can ascribe a discovered dulness to 
atelectasis. 

From what has been said hitherto, no difference will have been 
discovered between the s^Tuptoms of pneumonia and those of acquired 
atelectasis, and in reahty there is but one symptom by which we are 
enabled at the very first sight to discriminate between these two con- 
ditions. In pneumonia a burning hot skin is always present ; in atelec- 
tasis, on the contrary, it is absent. But when, in a rachitic child, with 
acquired atelectasis casually, or from dentition, or some other acute 
affection, fever becomes superadded, then no one is able to decide from 
one examination as to the correct diagnosis. Only the course of 
the accidental complication, the continuance of the dyspnoea and the 
respiratory modus after the fever has disappeared, can dear up the 
obscmity and aid us in the diagnosis. This diagnostic difficulty is an 
additional reason why pneumonia should not be treated instantly by 
leeches and antiphlogistics. In all cases such a treatment agTees 
very badly with rachitic children. 

The progress of rachitic acquired atelectasis is always very grad- 
ual ; the course is chronic, and may be prolonged for years. AYith 
increasing invigoration, and recommencing growth of the ribs, the 
respirations become slower, the strong inward curving of the fourth to 
the eighth ribs decreases with every inspiration, the pigeon-breast 
subsides, the auxiliary respiratory muscles of the neck and alse nasi 
cease to participate actively. 

But if no such consolidation of the thorax takes place after several 
months, and if the atelectasis progresses and implicates still larger 
2Dortions of pulmonary tissue, then the portions that still remained 
normal will be unable to perform the extra amount of labor thus im- 
posed upon them. A still more intense bronchitis is now liable to 
supervene, and the subjects die from paroxysms of suffocative coug-h, 
after having suffered for weeks, and even months, from the most vio- 
lent dyspnoea. OEdema of the feet precedes death in these cases some- 
times several weeks. 



DISEASES OF THE RESPIRATORY ORGAXS. 301 

The prognosis depends upon the degree and the duration of the 
conditions. The more developed the pigeon-breast, the more exten- 
sive the solidification of the tissue, the greater the dyspnoea, the more 
imminent is the danger of the child's being carried off by a slight 
bronchial catarrh, or by hydrsemia, in consequence of defective meta- 
morphosis of the materials. And yet, even very decided disfigure- 
ments of the thorax, and the atelectasis resulting therefrom, are often 
completely recovered from. 

Treatment. — The first question always is that of the nutrition, 
the second that of the residence. As the pigeon-breast only devel- 
ops itself from the sixth to the ninth month, the children are usually 
already weaned and fed upon various kinds of broths and soups. 
However, it is not possible to maintain that any of these methods of 
nutrition are absolutely injurious, for upon all of them great numbers 
of children thrive as well as die ; and it cannot even be decided which 
of these ward off the rachitis best, for it occurs in all kinds of diet and 
all manner of nutrition. The most important point in this relation is, 
that the food should be well borne and assimilated, and that no diarrhoea 
or other kinds of digestive disturbance be produced by it. Children 
with perfectly regular digestion very rarely become rachitic. 

Li\dng in damp houses materially promotes the production of 
rachitis, on account of which it is also much more frequent in winter 
than in summer, and among the poorer class of people than among 
the rich. Consequently, the treatment must be chiefly directed to the 
procurement of well-ventilated, dry rooms, and as long a residence in 
the country as possible. Where these conditions are unattainable, the 
termination will generally be unfavorable. Our efforts to eradicate 
the bronchitis, which invariably accompanies atelectasis, by the use of 
expectorants, narcotics, or any other class of remedies, will almost al- 
ways be fruitless. This complication subsides spontaneously, as soon 
as the lungs have again acquired a more capacious and better condi- 
tion. I confine my treatment to inunctions of fat upon the breast, 
several times daily, and internally give ol.jecor., or the malate of iron, 
more precise indications for which will be given further on, in the 
treatment of rachitis. 

(4.) Pulmo:n"Ary Emphysema {to e[X(phG7][ia, to inflate). — Tlie well- 
known blubber-like emphysema of the lungs, from w^iich adult patients 
acquire a barrel-like thorax, and suffer from displacement of the heart 
and diaphragm, is scarcely ever seen in children ; indeed, this kind 
of rarefaction of the pulmonary tissue seems to be altogether absent 
in the infantile organism. On the other hand, a vesicular and inter- 
stitial emphysema is often found under the following pathological con- 
ditions : 



302 DISEASES OF CHILDREN. 

Pathological Anatomy. — Purely vesicular emphysema consists in a 
permanent dilatation of a large section of pulmonary alveoli, which, 
however, are not ruptured, but only distended to perhaps twice their 
normal size. This species of alteration of the pulmonary tissue is 
almost invariable in the vicinity of condensed portions ; thus along 
with pneumonia, atelectasis, and tuberculosis, it is often found. Em- 
physematous lungs do not coUapse on opening the thorax, have a pe- 
culiar feel, like a cushion filled mth air, are grayish or yellowish gray, 
anasmic, and, when incised, collapse with a hissing, slightly-crepitating 
sound. "\^Tien the condition is of long-standing and in progressive 
atrophy of the alveolar w^aUs, interlobular emphysema invariably be- 
comes superadded. 

This condition consists in an accumulation of air in the cellular 
tissue connecting the different pulmonary lobules with each other, and 
can only be produced by the rupture of some of the pulmonary cells, 
and by the escape of air into the adjacent interlobular interstices. 
Larger or smaller transparent air-bubbles then appear on the surface 
of the lung, beneath the pleura, which may be displaced in the direc- 
tion of the interstices, and also ramify into the deeper structures of 
the lung. Sometimes they circumscribe a pulmonary lobule, in the 
shape of an island, and, when the interlobular emphysema has devel- 
oped itself between many neighboring lobules, form large air-bubbles, 
w^hich may be pushed hither and thither over extensive portions of the 
23leural surface of the lung. The escape of air into the connective 
tissue surrounding the bronchi, into the mediastinum anticum, and 
thence out upon the neck and breast, is a very rare occurrence. These 
instances almost invariably terminate fatally. 

In regard to the origin of the ordinary emphysema, many, and in 
part untenable, views still exist. It is certain that soHdification of one 
portion of the pulmonary parenchyma will produce a vicarious vesicu- 
lar emphysema of the rest of the tissue, and that, in the autopsies of 
atrophic children, principally as the efi"ects of enteritis folliculosa and 
cholera infantum, interlobular emphysema is usually found. I have 
formed no positive conclusions upon the occurrence of emphysema from 
pertussis, as stated in so many text-books ; on the whole, I am unable 
to recall a single instance of ever having met with it in the autopsy of 
a child who died from pertussis or any of its comphcations. JRilliet 
and Barthez also are opposed to the recognition of this complication ; 
and it follows from this that, aside from the mechanical distention 
of the alveoli, which, in forced expiration, too, may be produced at 
the expense of the amount of blood in the lungs, still another special 
disturbance of the nutrition of the alveolar walls must be present, 
^vithout which, notwithstanding all exciting causes, no emphysema 



DISEASES OF THE RESPIRATOKY ORGANS. 303 

could be brought about. Tlie inflation of air, in asphyxiated new-born 
children, has been suggested as an additional cause, but which is not 
very probable, in view of the fact that the lungs of the new-born 
child may. be inflated, after death, with all the strength possible, with- 
out rupturing their air-vesicles. The lungs are so distensible, and, by 
forced inflation, may be enlarged to such a degree, that one lung will 
fill up the entire thoracic cavity, and yet, as soon as the air is allowed 
to escape, it collapses again, without leaving the least trace of em- 
physema behind. 

Symptoms. — In children, the barrel-like shape of the thorax never 
develops itself, because, as it appears, they scarcely ever suffer from 
chronic, but always from acute emphysema, and, for that reason also, 
that depressed state of the diaphragm is not produced. Hence, we 
have no physical signs for it, and it is a very great question whether 
the acceleration of the respiration, mentioned in the text-books, had 
not better be imputed to the pulmonary afiections producing the em- 
physema than to the emphysema per se. This condition, therefore, is 
only of anatomo-pathological importance. The prognosis and the 
therapeutics, in a disease in which the diagnosis is so uncertain, are, 
of course, altogether out of the question. 

(5.) (Edema Pulmonijm {oidv/na, a swelling). — In most of the dis- 
eases of the heart, of the large vessels, and of the lungs, a rapidly-fatal 
pulmonary oedema supervenes as the final pathological state. Then, 
of course, it has but little importance as a pathological condition, and 
is only to be regarded as the beginning of death. On the other hand, 
in measles, and more frequently in scarlatina, a rapidly-developed pul- 
monary oedema is met with. It does not, however, always lead to 
death, but disappears spontaneously or by proper remedies. It is to 
this latter form in particular that our attention is to be directed here. 

Pathological Anatomy. — By pulmonary oedema we understand a 
transudation of serum into the pulmonary alveoli, the finest bronchi, 
and into the interstitial tissue. Neither the first nor the last alone 
can become infiltrated with serum without the participation of the 
others ; and the disputes of some authors, whether the oedema has its 
site in the alveoli, or in the interstices, may therefore be decided in 
favor of both. QEdematous lungs do not collapse on opening the 
thorax, are of a grayish-blue or yellowish-gray color, according to the 
quantity of blood in the afi'ected parts, are heavier than the healthy 
lung, swim in water, and crepitate strongly on pressure. The press- 
ure of the finger leaves a pit behind, for the corresponding pleura is 
also oedematous. On section, the oedematous lung presents a smooth 
glistening surface, from which a large quantity of reddish or yellowish 
fine-frothy serum escapes on the least pressure. The escape of this 



304 DISEASES OF CHILDREN. 

frotli is also accomjaanied by a hissing or crepitating noise. CEdema 
of the lungs is never confined to small portions of the pulmonary tissues, 
but generally affects the lower lobes of both lungs, a proof that its 
cause is not a local, but a general one, and that it must be due to a 
disturbance of the circulation. (Edematous lungs may be inflated, and 
thus it is seen that not all the alveoli are filled with serum. The cor- 
responding bronchi contain mucus, and in the bronchi of the higher 
order a similar frothy serum, like that which oozes out from the cut 
surfaces, is always found. 

Symptoms. — The predominating symptom is a marked dyspnoea, 
which rapidly becomes aggravated to such a degree as to actually en- 
danger life by suffocation, and may terminate fatally in a few hours. 
When the children are already large enough, and when their strength 
allows them, they will raise themselves and sit upright in bed, in order 
to acquire the utmost dilatation of the thorax possible. Small children 
while in the recumbent position are seized with severe fits of suffoca- 
tion, rendering it necessary to raise them up immediately. The breath- 
ing is extremely rapid, gasping, and rattling, and the voice grows low 
and indistinct. The cough is loose ; older children produce also a little 
white foam at the mouth. The pulse is very small, but, as regards 
the number of beats, stands in no relation to the frequency of the 
respiration. 

In extensive oedema the physical investigation gives a less sono- 
rous but never a completely dull percussion-sound. As oedema of the 
lungs is mostly bilateral, and the dulness not very intense, percussion 
therefore often furnishes no very satisfactory information concerning 
the existing alteration of the lungs. Auscultation is of greater im- 
portance. Extensively-diffused, moist, sibilant rales are heard over the 
oedematous places, which the practised ear readily distinguishes, by the 
coarser and less regular sound, from fine crepitation of pneumonia. 
They are often drowned by the large sonorous rales produced in the 
larger bronchi by the accumulation of mucus within them, but these, 
after a violent cough, momentarily disapjDcar. If a hand is laid upon 
the chest, it will feel these rhonchi extremely strong, v/hile crepitation 
usually is not perceived by palpation. It is very difficult to distin- 
guish pneumonia from oedema of the lungs, especially in those acute 
cases of oedema where it is attended by active fever. The dyspnoea, 
if possible, is even greater in oedema than in inflammation of the lungs, 
but the physical examination supplies no characteristic differences ; 
the only symptom that tends to make the existence of oedema tolerably 
certain is the bilateral appearance of crepitation, while lobar pneu- 
monia very generally is only observed on one side. 

The prognosis, if the cause of the condition is not due to cardiac 



DISEASES OF THE KESPIRATORY ORGANS. 305 

disease nor to a clironic disease of tlie lungs, is not so unfavorable as 
the first impression would lead one to suppose. Children attacked by 
neplu-itis and consecutive oedema of the lungs, after scarlatina, fre- 
quently suffer from the most intense dyspnoea, their faces are disfigured 
by s"svelling, and one supposes that a speedy end may be prognosti- 
cated with certainty ; but after a while they rally somewhat, the albu- 
men and casts in the urine diminish, and at the same time the urine is 
voided in increased quantities. 

Treatment. — For nephritis after scarlatina as a cause of this pul- 
monary affection, the antiphlogistic treatment, with calomel, purga- 
tives, and abstraction of blood, has proved itself to be decidedly injuri- 
ous. The dyspnoea of older children may indeed be rapidly relieved 
by venesection, but it soon becomes as torturing as before, and, anaemia 
now having become superadded, the condition will be found to be 
vastly aggravated. A large number of dry cups applied to the back 
and breast mitigates the dyspnoea very considerably, and this remedy, 
may be repeated once or twice daily without any harm or special an- 
noyance. The utmost attention is to be paid to the state of the skin, 
which should be made to act energetically. The best means by which 
to accomphsh this purpose is to wash it with a highly-diluted solu- 
tion of lye. The secretion of urine, according to the observations 
which I have hitherto instituted, is not stimulated by any remedy so 
well as by the widely-known and popular roob * juniperi, of which half 
a teaspoonful may be given once or twice daily. It has also the ad- 
vantage of having no unfavorable effect upon the appetite and stools, 
and that, mixed with syrup or honey, children are able to take it 
for a long time. The other diuretics, squills, digitalis, and acetate of 
potash, taste badly and their use is attended by numerous concomitant 
disagreeable effects, and therefore they are much less appropriate than 
rooh juniperi. In the higher grade of dyspnoea an emetic of ipe- 
cacuanha and tartarized antimony often performs very efficient service. 

(6.) HjemoPvKHAge feom the Lungs [Hmmorrhagia Pulmonitm 
— Hmmoptysis). — Three kinds of bleeding from the lungs are known 
to occur in the adult — either in the form of bloody sputa for a long 
time, or the blood suddenly bursts out from the mouth and nose in a 
stream, or the patient sinks down in a state of unconsciousness, and, 
after he has regained his faculties, is seized with coughing up of 
blood. In children, so far as I am aware, the second form only oc- 
curs, and is a complication of two very different conditions, whooping 
cough and tuberculosis. In some epidemics of pertussis, large quan- 
tities of blood are very frequently poured out from the mouth and 
nose, but the invariably favorable course, the absence of consecutive 

* See note ou page 223. 
20 



306 DISEASES OF CHILDREX. 

bloody sputa and all other bad effects, give rise to tolerably well- 
grounded doubts whether the blood does actually come from the 
lungs, or whether it is not merely the effect of the violent paroxysms 
of cough, and comes from some small lacerated vessels or capillaries 
in the larynx. The last of the two just-mentioned sources seems to 
me, in fact, to be the most probable. 

Pulmonary haemorrhage of tuberculous children is exceedingly 
rare. One may see hundreds of them perish from phthisis pulmonalis 
without meeting with a single instance of haemoptysis, and where it 
does occiu- it is not always seen at the commencement of the tuber- 
cular process, but as a closing scene a few days before death. I have 
never yet observed it in infants, and only once in older children, and 
that was in a girl ten years old. 

The treatment of haemoptysis, as an effect of pertussis, may be 
found in the section devoted to that subject. That occurring in tuber- 
culous children is only symptomatic, and consists enth^ely in the 
administration of small doses of narcotics to palliate the cough, and 
for the purpose of procuring euthanasia. 

(7.) H^iroPTOic PuLMOXAET Inparctiox. — This morbid lesion 
of the lungs, first accurately described by JLaennec^ is not very unfre- 
quently observed in the autopsies of children who have perished from 
purpura or pulmonary tuberculosis, and is even found in the new- 
bom child, but in the latter it is generally compHcated with pyaemia 
and the formation of emboli in the lungs. 

Pathological Anatomy. — In one lung, and sometimes in both, red- 
dish-black spots, of the size of a pea up to that of a walnut, are 
found, which are sharply defined from the rest of the pulmonary 
tissue, and of decidedly gTcater resistance. The cut surfaces are not 
dry and smooth, but slightly granular, and the portions of the lungs 
thus altered are almost as friable as the hepatic parenchyma. The 
cause of this darker color and augmented resistance is to be found in 
an extravasation of blood, which has filled up a large number of al- 
veoli, and compressed the interstitial substance. The slightly-granu- 
lar appearance of the cut surfaces is also explained by the circum- 
stance that the coagulated blood represents a precise cast of the 
cluster-like arrangement of the alveoli. On scraping such a cut 
surface with the back of a scalpel, a bloody fluid, mixed with fine, 
granular blood-coagula, is obtained. 

There is great danger of confounding this condition with croup- 
ous pneumonia. But, if due attention is given to the circumscribed 
form of the haemoptoic infarction, its dark-red color and sharp boun- 



DISEASES OF THE RESPIRATORY ORGANS. 307 

daries, and the dark-red granular serum, which may be scraped off 
the cut surfaces, it will then hardly be possible to entertain any doubt 
in regard to the nature of the lesion. When these infarctions have 
become developed between dark-red hypostatic congested tissues, be- 
hind and below for instance, the distinction of color is then lost ; still, 
the greater compactness and fragilitj^, likewise the absence of air- 
bubbles, supply sufficient cardinal points. Haemoptoic infarctions are 
oftener central than peripheral, and, in the latter case, glisten through 
the pleura. The bronchi leading to them, up to a certain grade, are 
filled with coagula ; the blood, however, generally does not extend 
very far upward, and consequently no bloody sputa are expectorated. 

This condition, according to HoJcitansTcy , is often attended by ac- 
tive softening of the right side of the heart, and in severer forms may 
become comphcated with rupture of the pulmonary tissue, when large 
cavities may be seen filled with blood and loose pulmonary substance. 
According to the same author, it is also possible for a retrograde de- 
velopment to take place, the infarction either becoming liquid, and 
assuming a blackish-brown, or rusty and wine-yeast-like color, and 
thus partly absorbed, partly expectorated by the bronchi, or the coagu- 
lated blood shrinks and is metamorphosed into an obsolete fibrous or 
brown amorphous tissue. In grave instances, the infarction may also 
become gangTenous, and then present the signs of a perfect gan- 
grene of the lungs. 

Symptoms. — Hsemoptoic infarction is never idiopathic, but always • 
complicated with purpura, tuberculosis, and cardiac affections ; in all 
cases the dyspnoea and fever become vastly aggravated by its appear- 
ance. Neither by physical examination, nor by any symptoms other- 
wise developed, are we able to distinguish this condition from lobular 
pneumonia. Most of the physical signs are devoid of importance, for 
the reason that the infarction usually occurs about the roots of the 
lungs, and not on their periphery. A special treatment in a malady so 
deficient in diagnostic symptoms as this, is, of course, impossible. 

(8.) GANGEEiq-E OF THE Lu:n'gs [GcmgrcGna s. Mortificatio Put- 
monum). — Gangrene of the lungs is an exceedingly rare affection m 
children. It occurs after traumatic pneumonia, produced by foreign 
bodies, which, during a forced inspiration, have found their way into 
the lungs, and in the mahgnant course of acute exanthemata, in noma, 
in abdominal typhus fever, in pyaemia, and, lastly, as an unfavorable 
termination of haemoptoic infarction. 

Pathological Anatomy. — Since Laenne(^s time a difused and a 
circmnscribed gangrene of the lungs have been distinguished. 

The characters of the diffused are : Spreading of a dirty-greenish 
or brownish-colored putrid slough over larger portions of a lung, over 



308 DISEASES OE CHILDREN. 

one lobe, or an entire lung, or the tissues, lia^dng become totally lique- 
fied, have a gangrenous odor, and are infiltrated witli a flocculent, 
froth J, gangrenous-odored ichor. This kind of mortification is no- 
where strongly defined, but gradually merges into healthy structures, 
larger or smaller streaks of oedematous tissue being interposed be- 
tween the gangrenous and sound portions of the lung. It is very 
rarely observed alone, but generally associated with circumscribed 
gangrene. 

Circumscribed gangrene is oftener met with than the jDreceding. 
In this process, a small portion of the tissues at one place becomes 
transformed into a gTeenish-black, moist, not easily-lacerable crust or 
slough, which is sharply defined. In the infant, the size of this slough 
rarely reaches that of a walnut. After a while this gangrenous plug 
becomes detached from its normal surroundings, and lies in an exca- 
vation of gangrenous pulmonary parenchyma, and bathed by a gan- 
grenous ichor ; or it soon dissolves into a sanious, ichorous fluid, and 
is surrounded by a sloughing excavation, T\4th irregular, shaggy walls. 
Its site is oftener on the periphery, and in the lower lobes, than in the 
centre of the lung, and, after it becomes detached, it will drop into the 
pleural sac, if the pleura is not imphcated and firmly united with the 
costal pleura. This accident results in an ichorous pleuritis, and pneu- 
mothorax becomes developed. 

The pulmonary tissue surrounding the gangrenous plug is either 
only oedematous or pneumonic to variable extents ; in both instances 
there is a disposition to assume a difiiised mortification, and thus, if 
the children have lived long enough mth this dreadful disease, an en- 
tire lobe may be found transformed into a pultaceous, sanious mass. 
If the arteries coursing through the affected places do not become 
completely occluded by thrombi, serious hgemorrhage may ensue, the 
blood escaping by the bronchi, while that which accumulates in the 
gangrenous cavities tends to increase the gangrenous material. No 
recovery from traumatic gangrene of the lung has been ever observed. 

Symptoms. — The symptoms vary according to the cause of the gan- 
grene. In typhus fever, in noma, and malignant measles, the general 
disease is so severe, and the susceptibihty to the pain, at the same 
time, so diminished, that no subjective symptoms whatever, and only 
a few objective sjTnjDtoms, become noticeable, while traumatic gan- 
grene begins with the symptoms of pneumonia. I once met with such 
a case, in which a boy, fourteen years of age, had a grain of corn in 
his mouth, and, from some cause or another, suddenly commenced to 
laugh, during wliich the grain slipped into his larynx. For several 
days thereafter he was still tolerably well, and it was supposed that 
lie was mistaken, and that he had swallowed the com. But all the 



DISEASES OF THE RESPIRATORY ORGANS. 309 

symptoms of pneumonia at length suddenly came on, but did not run 
the regular course. The sputa became gangrenous, and, through vio- 
lent paroxysms o£ coughing, the patient expectorated portions of the 
grain of corn, and large quantities of sloughing shreds, whose odor 
contaminated the atmosphere of the room to an unbearable degree. 
This expectoration continued for several weeks, and did not stop com- 
pletely until after many months. The boy was reduced to a mere 
skeleton, and a cavity in the lungs remained, which gradually has 
diminished in size, and now, after six years, is barely traceable. Many 
years elapsed before he regained his former health and appearance. 
This case of gangr^ena pulmonum is the only one that I have seen 
terminate favorably. 

In the other, non-traumatic, cases of gangrene of the lungs, the 
disease makes its appearance by a sudden aggravation of the general 
condition, in which the face, in particular, quickly becomes changed, 
assumes a leaden hue, and a distorted Hippocratic facies^ and the 
pulse becomes extremely small and rapid. The temperature of the 
skin is not increased; the putrid odor from the mouth is always 
the most pathognomonic sign, which cannot be attributed to any 
morbid alteration in the mouth. The physical investigation may 
prove barren of results, if the process is central, or there be feebly 
circumscribed dulness, crepitating rales, bronchial breathing, and sibi- 
lant rales, or when perforation of the lungs occurs, and signs of pneu- 
mothorax appear. Generally, the sputa are bloody, the cough is in- 
tense and spasmodic. Colliquative sweats, hectic fever, and delirium, 
soon become superadded, after which death almost invariably closes 
the scene. 

Treatment. — Where death appears to be inevitable, any rational 
treatment must be doubtful. The recoveries observed hitherto have 
been achieved by a treatment with quinine, mineral acids, acetate of 
lead, chlorine and its preparations, and, finally, with creosote. 

(9.) Tuberculosis of the Lungs ais^d Broitchial Glands. — 
Since we intend to subject the dyscrasiae, as collective diseases, to a 
detailed discussion in a special section, it will be sufficient, for the 
sake of completeness, to speak here of the pathological anatomy and 
symptomatology of pulmonary tuberculosis, while the etiology and 
consideration of the general disease will be treated of along mth the 
dyscrasise. 

Pathological Anatomy. — All kinds of tuberculosis occur in the 
infantile lung. Thus there is (1), the discrete or miliary tubercle; 
(2), the aggregated; and (3), the large cheesy tubercular infarction. 
All the three varieties are often met with in one lunof. 

Miliary tubercle originates in the pouring out of a rich fibrous 



310 DISEASES OF CHILDREN. 

exudation into the pulmonary alveoli. Usually, not many alveoli near 
to each other are thus involved, and still less frequently is an entire 
lobule. The process is mostly confined to solitary pulmonary vesicles 
only, and thus the name of discrete tubercle has been very appro- 
priately selected. It occurs as a small nodule, barely as large as a 
pin's head, is of a grayish color, microscopically of a perfectly amor- 
phous nature, for, with the exception of a few epithelium-cells and 
elastic fibres from the adjacent interstices, nothing but detritus is 
found. Acetic acid slowly dissolves it. 

The aggregated tubercle consists of the same amorphous detritus 
as the miliary, is situated in clusters or nests, and may be found dis- 
persed throughout several lobules and has a deeper yellowish tint. 
The pulmonary tissue lying between the single tubercles of such a 
nest is always devoid of air, solidified, and filled mth exudation. 

The tuberculous infiltration extends over large portions of the lungs, 
half of, or even over an entire lobe ; in children, unlike adults, it oc- 
cm^s oftener in the lower lobes than at the apices of the lungs ; has an 
undefined, ujihmited form, and a yellow cheesy consistence. On these 
large tubercular infiltrations, the process of softening and degeneration 
can be studied to the best advantage. The tubercular mass, which 
has finally attained to a semifluid consistence, is evacuated by a 
bronchus, and a partly filled or a completely empty cavity remains, in 
the walls of which new tubercles may be deposited, and then, by the 
softening of these, the cavity is still more enlarged. Thus irregular, 
excavated cavities, provided with various prolongations, finally result, 
and are filled up with a dirty crumbling, yellow, or gray pus. Some- 
times several small ones, then again a single one, so large as to 
occupy the whole lobe, may occur. In this connection it may be 
well to remark that a cavity seldom encroaches upon the adjacent 
lobes, but always leaves the demarkations naturally existing between 
them uninjured. Large caverns always communicate with some 
bronchus, whose open mouth is seen sharply cut off and adherent to 
the walls of the cavity. Occasionally obhterated vessels, or remnants 
of parenchymatous tissue, run like strings or bridges across the cavity. 
These vessels, however, invariably seem to be obliterated, for haemop- 
tysis is so extremely rare in children as nowhere to be mentioned as 
ever having been observed. So, too, the rupture of a cavern into the 
pleural sac, with pneumo-thorax resulting therefrom, so far as I am 
aware, never occurs in tuberculous children. That the pulmonary 
parenchyma surrounding a cavity is never perfectly norm^al, but al- 
ways solidified hke cicatricial structures, or in a state of gTay or 



DISEASES OF THE EESPIRATORY ORGANS. 311 

red hepatization, containing more or less tubercles, is well known. 
(Edema is also frequently met with, especially in the lower lobes, 
while a vicarious emphysema usually involves the upper lobes. The 
bronchi which communicate with the cavities contain a yellow, crum- 
bling pus like that found in the caverns, while the rest exhibit a 
swollen and injected mucous membrane. According to Jlasse, the 
branches of the pulmonary artery leading to the tubercular cavities 
and infiltrations become obliterated, but new ones are formed in the 
parts of the lung that have sujffered a loss in their principal vascular 
network. This increased vascular suj^ply comes from the bronchial 
arteries and in part from the intercostal, the blood being carried off 
again by the bronchial veins and vena azygos. A disturbance of the 
circulation ensues, with which the partial dilatation and unusual de- 
velopment of the subcutaneous veins may have some connection. 

Cavities, as is well known, may heal by calcification or by cica- 
trization. For both methods of healing, a number of years of time is 
undoubtedly necessary, and this readily accounts for the rarity with 
which they are observed in the autopsies of infantile cadavers. Cal- 
cification never occurs in children ; dense, puckered places, on the other 
hand, are often seen conjointly with still-existing cavities, and are, 
most jDrobably, to be regarded as the cicatrices of smaller cavities. 
The tubercular lung of an infant is distinguished from that of the 
adult by the absence of pigmentation. 

The hroncJiial glands are much more frequently the site of tuber- 
cles than the lungs. This is invariably the case when tuberculous 
degeneration exists in the lungs ; but often, even where they are not 
implicated. Here the large yellow tubercle principally occurs, while 
the aggregated clusters of small tubercle are rarer, and the miliary va- 
riety is scarcely ever observed. 

Generally, the whole gland degenerates into a large yellow tuber- 
cle, and attains to the size of a small hazel-nut, and even to that of a 
walnut. The tuberculosis mostly implicates several glands, so that 
the bifurcation of the bronchi becomes surrounded by a large tuber- 
cular mass. Only those glands lying external to the lungs attain to 
a considerable size : those accompanying the bronchi within the lungs 
barely become larger than an almond, or dispose themselves in semi- 
lunar channels about the bronchus. The glandular parenchyma, as a 
rule, has wholly disappeared, and nothing but a capsule, the former 
enveloping membrane of the gland, remains, to which a yellow tuber- 
culous mass adheres all around. These seem to be less disposed to 
softening ; remarkably seldom, at all events, are soft tubercles found 
in the glands, but, when that process does take place, it may begin in 
the centre as readily as at the periphery. In older children a partial 



312 DISEASES OF CHILDREN. 

calcification may also occur. The influence of the tuberculous bron- 
chial glands upon the adjacent organs is twofold, as JRilliet and 
Sartliez very correctly have pointed out. They say that glands act 
either (1) by compression, or (2) by firm adhesions with the contiguous 
organs and consecutive perforation. 

(ad 1.) Anatomists divide the glands that are situated external to 
the lungs into {a) tracheal glands at the side of the trachea down to its 
division ; into (^) bronchial glands, lying between the bifurcation ; 
into (c) cardiac glands, lying upon the base of the heart and large ves- 
sels ; and into (c?) oesophageal glands, within the mediastinum posti- 
cum, in the neighborhood of the oesophagus. All these glands may 
undergo tuberculous degeneration and enlargement, and then press 
upon the adjoining organs. 

As regards the compression of the vessels, Ave find those which are 
liable to it to be the superior vena cava, the pulmonary artery, the 
pulmonary veins, and the vena azygos. Instances of the total obliter- 
ation of these veins by this means are recorded. I myself have never 
met with such, but only remember to have seen a constriction of a 
pulmonary vein with simultaneous tubercular degeneration of the bron- 
chial glands. Compression of the vessels may give rise to haemorrhage 
and oedema. Thus, for example, according to the authors above 
quoted, compression of the vena cava superior jDroduced a haemorrhage 
into the arachnoid sac, and oedema of the face. Pressure upon the 
pulmonary vein may very readily cause oedema of the lungs. 

Impressions upon and flattenings of the trachea and its bifurca- 
tion are sometimes found, and are also produced by tubercular glands. 
They are not, however, capable of effectmg any decided diminution of 
their cahbre. Compression of the nerves is of greater importance, 
especially of the pneumogastric nerve. Sometimes the glands grow 
so closely around them, that it becomes an actual impossibility for the 
anatomical knife to separate them. Nevertheless, the nervous func- 
tion does not seem to be interfered with, for, were it otherwise, more 
marked disturbances of the circulation and of the respiration would be 
observed in glandular tuberculosis than is actually the case. Compres- 
sion of the oesophagus seems to occur but very rarely ; a simple lateral 
dis]Dlacement is sometimes observed. 

(ad 2.) The bronchial glands within and outside of the lungs may 
become intimately united Avith the bronchi, and perforation of the 
walls of the bronchi may ensue fi'om the softening that follows. Ac- 
cording to Rilliet and Barthez, non-softening, hard, tubercular nodes 
are also capable of producing ulceration of the rings of the bronchi, 
and thus occasion perforation, a condition that has hitherto received 
but httle attention from the pathological anatomist. In the lung 



DISEASES OF THE EESPIRATORY ORGANS. 313 

itself it is very difficult to distinguish a cavity from a perforated bron- 
chus in a suppurating bronchial gland. These pseudo-cavities are 
always situated near the roots of the lungs, and outwardly their excava- 
tions are in connection with the rest of the tuberculous masses of the 
degenerated glands. 

The authors referred to also speak of a tuberculous perforation of 
the pulmonary artery, and of the oesophagus, of which I have no per- 
sonal experience. 

Symptoms. — First of all, as regards the physical examination, it 
is important to understand that the percussion should be performed 
lowly ; and the strokes follow each other very slowly, for otherwise the 
less-marked dulness will invariably be overlooked. In miliary tuber- 
culosis, where both lungs are equally permeated by the minute tuber- 
cles, percussion, of course, affords less information ; the percussion- 
sound m general is a little more tympanitic, but no inequality in the 
two pectoral moieties can be detected. The same holds good with 
tuberculosis of the bronchial glands, which are overlapped by the 
lungs and roots of the large vessels, and thus totally escape the 
physical diagnosis. On the other hand, extensive tuberculous infiltra-. 
tion may very readily be detected by careful percussion, but, as has 
abeady been stated, when treating of the pathological anatomy, the 
apices of the lungs are not so exclusively the site of these infiltra- 
tions. A circumscribed dulness is very frequently found farther down 
or laterally, which is also referable to tuberculosis, although in 
adults it seldom occurs in this manner. If caverns have already 
formed and evacuated their contents by the bronchi, the flat percussion- 
sound becomes a little more sonorous, and acquires a tympanitic pitch, 
a condition that by no means indicates improvement nor diminution 
of the tuberculous infiltration. 

Nothing characteristic is detected by auscultation ; the bronchial 
catarrh always attending upon this disease gives rise to far-diffused, 
large and small sibilant rales, which differ in no respect from those of 
a simple bronchitis. In large tubercular solidifications of the pul- 
monary substance there is always bronchial respiration, strong con- 
sonance of the voice and of the cough, and distinct abnormal propa- 
gation of the cardiac sound to parts of the lungs at a distance from 
the heart. Occasionally crepitating rales, or merely roughened res- 
piration, is heard at the margin of the dulness. The cardiac impulse 
is remarkably strong in all tubercular children. Wlien a solid tuber- 
culous infiltration liquefies, and cavities are formed, the auscultatory 
symptoms likewise become changed, as has already been pointed out 
when treating upon percussion. Cavernous gurgling and rales now 
supervene, and the breathing becomes cavernous. Cavities, however, 



314 DISEASES OF CHILDREN. 

in small children, as a rule, are not of such a size that these symptoms 
should always appear, and be perfectly characteristic. 

As regards the functional symptoms, these will be found to be of 
various descriptions. The respiratory acts are almost always acceler- 
ated, most rapidly in febrile, acute tuberculosis, where the two factors, 
(1) the fever, and (2) mechanical obstruction in the air-passages, act 
in combination. They then rise from sixty to eighty in the minute. In 
chronic tuberculosis the acceleration is barely perceptible, and scarcely 
any dyspnoea is present. But, in the rapidly-developing and pro- 
gressive form, great dyspnoea, even orthopnoea, and labored breathing, 
participated in by the alse nasi, may become superadded. This, how- 
ever, is to be ascribed more to the concomitant pleuritis and partial 
tuberculous pneumonia than to a constriction of space, in consequence 
of the tuberculous deposit. In general it may be assumed that the 
more acute and diffused the process in the lungs, the more accelerated 
and embarrassed are the acts of respiration. 

The cough is the most constant of aU the symptoms, for it is never 
absent altogether ; it is feebler and less noticeable in acute miliary 
tuberculosis, where the same process in other organs, particularly in 
the brain, reduces the irritability of the nervous system to such an 
extent that these hydrocephalic children often will not cough for 
many days, although the post-mortem examination may show that 
both lungs are found permeated by miliary tubercles, and the bron- 
chial glands metamorphosed into cheesy masses. 

The cough is not only the most constant, but also the earliest of 
all the symptoms. It never ceases completely during the entire 
course, although there may be short remissions which are liable to 
mislead one to the formation of a deceptive prognosis. At first it is 
dry, short, and hacking, but recurs frequently ; later, when large ex- , 
tents of bronchi are implicated, it becomes moist, and is attended 
by convulsive paroxysms. These paroxysms have great similarity to 
those of whooping-cough, but the characteristic, loud, and prolonged 
inspiration at the end of the cough is always absent ; nor does the 
expectoration of large quantities of glairy mucus set in after several 
wrecks. These spasmodic coughs, as a rule, have their foundation in 
the tuberculous enlargement of the tracheal glands, which exercise a 
constantly-increasing pressure upon and irritation of the trachea, and 
consecutively upon the larynx. It may also be occasioned by profuse 
secretion alone, as is often enough observed in adult patients suffer- 
ing from simple broncho-blennorrhoea. "When the latter cause exists, 
the paroxysm ceases as soon as the mucus has passed the larynx, but 
this cannot be so easily decided in children, since they immediately 
swallow it. In tuberculosis of the bronchial glands, on the other 



DISEASES OF THE EESPIRATORY ORGANS. 315 

hand, the paroxysms may continue for an indefinite time, and exist 
without any expectoration, and, as a rule, cease only when the ex- 
haustion has become extreme. 

The expectoration^ which in adult tuberculous patients supplies 
such an excellent index, cannot be relied upon at all in children up to 
the fifth or sixth year, for they invariably swallow the mucus coughed 
up from the larynx. But occasionally, even in young children, after 
a violent paroxysm of coughing, a white, fine-frothy foam will be seen 
to rise to the tongue, and even between the hps. This, however, can 
only be regarded as simple secretion of the bronchi affected with 
catarrh, and is by no means pathognomonic of tuberculosis. Children 
over seven years old, in whom, before the age of puberty, phthisis 
pulmonalis is very rare, expectorate like adults, and the pus evacuated 
from the vomicae is in all respects similar. The rare occurrence of 
haemoptysis has already been particularly mentioned, in connection 
with haemorrhage of the lungs generally, on page 306. 

If the children are large enough to indicate the place where they 
feel the pain, they will almost always describe its site to be at the 
praecordia or the sternum, only extremely rarely in the lateral parts 
of the thorax. It is absolutely necessary to ascertain whether any 
pains more or less violent exist, for the purpose of instituting a scien- 
tific treatment, for the more intense they are, and the greater the 
restlessness occasioned by them, the more rapidly the children sink. 
As tuberculosis is seldom Hmited to one lung, the alterations observed 
in the decubitus of such children are, therefore, less constant. They 
mostly he on the back, and only very seldom choose a constant lateral 
decubitus. It is remarkable that, notwithstanding the extreme ema- 
ciation, the long duration of the disease, and of the continued fever, 
they rarely and only at a late date get bed-sores. The walls of the 
thorax exhibit a degree of emaciation disproportionate to that of the 
rest of the body, and a development of the subcutaneous veins takes 
place, and may be regarded as characteristic of tuberculosis. These 
veins, especially in the neighborhood of the sternum, from the first to 
the third rib, become largely dilated, and may swell up to the width 
of one hne. 

In aU chronic diseases in vfhich any impediment to the circulation 
of the blood exists in the lungs, consequently in extensive tubercu- 
losis and cardiac aifections in particular, a peculiar bulbous swelling 
of the tips of the fingers is observed, by which the nails become 
curved forward like claws. In the highest grade of this curving the 
fingers acquire the appearance of drumsticks. In this we possess a 
very valuable sign, because this bulbous thickening of the ends of 
the fingers is never congenital, and is never observed in healthy 



316 DISEASES OF CHILDEEN. 

children, but always denotes the existence of a liigh degree of 
stasis in the right side of the heart, which, as a rule, has its cause in 
the lungs. 

Markedly enlarged bronchial glands, as has already been observed 
in speaking of the pathological' anatomy, sometimes give rise to 
oedema of the face — a condition that is to be ascribed to local dis- 
turbances of the circulation, because, in dropsies originating in the 
dyscrasi^e, the feet are well known to swell first, and oedema of the 
upper extremities and of the face does not supervene until a long time 
afterward, while in this case that of the face alone is present. JRilliet 
and ^arthez have shown, by several dissections in such cases, that 
compression of the vena cava by the enlarged glands has actually 
taken place. There is then also found a marked dilatation of the 
subcutaneous veins of the neck, and slight cyanosis of the lips and 
eyelids. 

Pulmonary tuberculosis runs its course either as acute miliary tu- 
berculosis, in which case the same process is also found established in 
other organs, especially in the brain and upon the peritonseuma, and 
the various symptoms emanating from the other organs, completely 
overshadowing those of the lungs, or it runs a chronic course as in the 
adult, under the signs of phthisis pulmonalis. The first form will be 
discussed once more in speaking of the cachexige ; the second has a 
duration of from two months to two years, and may also be arrested. 
I know children, the progeny of demonstrably tuberculous parents, 
Avho, in the early years of life, exhibited decided signs of developed 
pulmonary tuberculosis, such as distinct dulness over one or the other 
part of the thorax, bronchial breathing, sibilant rales, intense protract- 
ed bronchitis, emaciation, fever, etc., and nevertheless recovered, to all 
appearance, completely : the nutrition became reestablished, the ap- 
pearance of the child blooming, the fever and cough gradually sub- 
sided; but the dulness remained, and, with the least disturbance of 
the general condition, a new and obstinate bronchitis always recurred. 
But finally, in some cases, the process becomes general, and then the 
phthisical children perish under the symptoms of miliary tuberculosis. 

In regard to the treatment, the reader is referred to the precepts 
which will be recommended for tuberculosis in the section on the 
dyscrasiae. 

(10.) Cakcinoma of the Luis-QS Amy of the Mediastin-um 
Anticum. — Carcinoma in general is an extremely rare affection in 
children, and that of the lungs in particular has been observed but a 
few times. In most instances carcinoma of the lungs was found in 
the cadaver, along with cancerous deposits in other organs, in the 
form of white or grayish-red nodules of the most variable sizes. They 



nSEASSS OF THE RESPIKATORY ORGANS. S17 

are situated both in the deeper portions and upon the periphery of the 
lungs ; they are flattened down when deposited close to the pleura, 
and, hke cancer of the hver, become umbilicated in the centre. The 
symptoms observable during life are reduced to bronchitis and dysp- 
noea, and are usually supplanted by -^ose of carcinoma in other organs. 

Carcinoma of the TYiediastmuni anticwn I have observed twice — 
once in a boy five years of age, and once in a boy six years of age. 
Since, in both cases, the whole anterior mediastinum was filled up with 
it, and the pleura, lungs, and pericardium were united by it, a descrip- 
tion of the s}Tiiptoms at this place will therefore not seem improper. 

The development of this carcinoma seems to be tolerably rapid ; 
at any rate, both of these children manifested the signs of embarrassed 
respiration for a few weeks, and yet, at the percussion that was soon 
after performed, a marked dulness was already observable over the 
sternum, extending laterally to both sides of it. The main index is, 
therefore, the aforesaid dulness, which, in the course of the malady, 
rapidly increases, not only by the growth of the carcinoma, but 
also by the dropsical efinsion which is poured out into the pleural 
sac. That the exudation which gives rise to the dulness is not of a 
fluid natm'e, may be very easily demonstrated. The cardiac sound is 
heard over it almost as loudly as when the heart itself is auscultated ; 
the sibilant rales, too, originating in the catarrhal bronchi, are dis- 
tinctly audible over the cancerous tumor. The functional disturb- 
ances mainly depend upon the direction in which the cancer has most 
extended. The large venous trunks must have been compromised in 
both the cases I saw, for oedema of the face and hands was present, 
and the veins of the neck were markedly dilated. The children suf- 
fered from constant orthopnoea, on account of the extremely distress- 
ing compression of the anterior sections of the lungs, and breathed 
easiest when they curved the back and flexed the head forward, which 
attitude was also retained during sleep. The dorsal surface of the 
thorax gives, in these cases, a sonorous tympanitic percussion-sound, 
and, as this part of the lung must perform a double duty on account 
of the compromised anterior portion, the respiratory sounds are heard 
extremely intensified, and frequently masked by sibilant rales. The 
heart is displaced outwardly and downward, and, in one of the cases I 
saw, a blowing systolic murmur was heard without any material alter- 
ation of the heart or its valves being found at the autopsy by which 
that murmur could be explained. The pulse is very much accelerated, 
the appetite not wholly gone, and the emaciation, consequently, never 
becomes so extreme as in tuberculosis. Finally, much to the relief of 



318 DISEASES OF CHILDREN. 

the patients and of their relations, the brain also becomes affected, 
coma or delirium supervenes, and the patient soon succumbs. 

At the autopsy I found, in one case, a medullary carcinoma, which 
filled up the whole anterior mediastinum, and extended over the an- 
terior part of the right lung, ^fithout having occasioned secondary 
nodules in any other organ. In the second case, a cystosarcoma, of 
the size of a large fist, simply compressed, but did not involve the 
lungs and heart. In both, marked hydrothorax, but only slight ascites, 
were present. 

The dyspnoea of these children, which was extremely distressing 
to themselves, and for others to witness, could temporarily be miti- 
gated in a very surprising manner by large doses of morphia, gT. -J to 
-J pro die. 

(11.) Whooping-Cough {Tussis Convulsiva — Pertussis). — Whoop- 
ing-cough is an epidemic, contagious bronchial catarrh, mth peculiar 
convulsive paroxysms of cough. Sippocrates has not described it 
accurately. The delineations of the epidemics of the former centuries 
are not exactly applicable to the group of symptoms as it is now ob- 
served, and only since the eighteenth century have more correct views 
been entertained in regard to this disease in the different countries 
where it has prevailed. Besides the denominations above given, it has 
received a number of others, such as coqueluche, affection pneumo- 
gastrite-pituiteuse^ hroncho-cephalite, catarrh convulsif (in France) / 
chin-cough (England) ; pertussis^ tussis suffocativa^ spasmodica^ stran- 
gulans, clangosa, ferina, blauer Husten (blue-cough), Schaafshusten, 
Eselshusten (Germany). "VVe have to deal here with no simple anat- 
omo-pathological alteration, but with an acute cosmical disease, and, 
in fact, from the class of the so-called atmospheric pestilences. 

Symptoms. — Three stages of whooping-cough can be distinguished 
with tolerable accuracy — (1) a stadium catarrhale, (2) a stadium con- 
vulsivum, and (3) a stadium decrements 

(1.) Stadium. The phenomena of the stad. catarrhale^ or prodromo- 
rum, or invasionis, are those of a simple bronchial catarrh, sometimes 
complicated with gastric symptoms. Some hoarseness, tickhng of the 
throat, dry cough, sneezing, profuse flow of mucus from the nose, 
lachrymation and redness of the eyes, are together or singly observed 
in almost every child with commencing whoo23ing-cough. If febrile 
symptoms supervene, as frequently happens, such as hot skin, fre- 
quent pulse, depression, general malaise, and loss of appetite, then 
we have a perfect picture of the stage of incubation of measles, a fact 
which, when whooping-cough and measles prevail simultaneously in 
one place, we shall do well to keep in mind, on account of its bearing 
on the prognosis. The cough, from the very commencement, assumes 



DISEASES OF THE RESPIRATORY ORGANS. 319 

a peculiar, hollow, metallic clang, soon becomes paroxysmal, and, if no 
preexisting pulmonary affections are present, is always totally dry. 
This stage lasts from three days to three weeks, is more or less dis- 
tinctly marked, and can be observed in every case of whooping-cough. 
(2.) Stadium. Hhe stad. cwzvwfe^'ywmornervoswm is distinguished 
by the cough recurring in violent paroxysms, and which is of such a 
peculiar character that it is never forgotten again when it has once 
been heard. Somewhat older children have a premonition of the 
occurrence of the attack. They experience a tickling sensation in the 
throat, oppression of the chest, feel nauseated, breathe anxiously and 
quickly, sit upright in bed, or run, when they are awake, to a chair or 
some other support, in order to be able to offer a stronger resistance 
to the attack. The paroxysm itself consists of a great number of 
short, rapidly-recurring, not perfectly uniform, spasmodic coughs, and 
is at length interrupted by a protracted, whistling, sipping attempt at 
inspiration. The French designate this v/histling inspiration by the 
word " reprise." Immediately after the first one, the convulsive ex- 
pirations begin anew, last ten to fifteen seconds, whereupon another 
" reprise " follows, and thus these two acts alternate v^ith each other 
several times in such a manner that an entire paroxysm, from the be- 
ginning to the reappearance of the normal respiration, may last from 
one to fifteen minutes. At the beginning of the paroxysm, the single 
cough-exclamations follow each other with the greatest rapidity, and 
without any intervals, and the child seems to be in imminent danger 
of dying by suffocation. And in fact, during the fit of coughing up to 
the " reprise," no air whatever gains entrance into the lungs, a fact of 
which one can easily convince himself by auscultating the dorsal 
surface of the thorax. At the " reprise " the glottis is evidently in a 
state of momentary constriction, either in consequence of spasm, or of 
paralysis, as has been already more thoroughly explained during the 
study of croup, and all the auxiliary respiratory muscles of the neck 
and abdomen are called upon to perform an active part. Serious stag- 
nations of the circulation are produced by the choking acts of cough- 
ing ; the blood stagnates in the pulmonary artery, and then occasions 
dilatation of the right side of the heart and of the entire peripheral 
■ venous system, a condition that is especially distinctly to be seen in 
the large veins of the neck. Finally, the children become bluish red 
over the entire head and face, from which also the designation of 
" Blauhustens " (blue-cough) has originated. The eyes become in- 
jected, and protrude somewhat from their sockets. The face swells 
up, and is covered with a cold perspiration ; the movements of the 
heart and of the pulse are feeble and unequal ; the urine and foeces 
are often involuntarily ejected by the violent contractions of the ab- 



320 DISEASES OF CHILDREN. 

dominal muscles ; hernia and prolapsus of the rectum are also some- 
times occasioned thereby. The venous stasis gives rise to frequent 
hasmorrhages ; the most common are those from the mouth and nose. 
Whether the larger quantities of blood vomited and coughed up come 
from the lungs, as some believe, is very questionable, because very 
often no consecutive alterations of the lungs whatever, and no ag- 
gravation of the general condition, ensue therefrom, and a perfectly 
colorless mucus is expectorated in the paroxysms of cough that come 
on a few minutes thereafter. We know, however, that after an haemop- 
tysis, for instance in tuberculosis, the sputa continue to be bloody for 
several days. Extravasations of blood upon the conjunctiva bulbi, or 
into the loose cellular tissue of the eyelids, frequently take place, 
where the extravasated blood undergoes the same changes of color 
that we observe in external injuries. JBouchut relates a case where 
a child cried with real bloody tears, and states also that the haemor- 
rhages in pertussis may sometimes become so profuse as to endan- 
ger life, an occurrence that I have never yet experienced. So, too, 
the bleedings from the ears, of which mention is made in most of the 
text-books, I have never observed ; nevertheless I do not doubt that 
they have been seen, especially in cases of otorrhoea, and ulcerations 
of the external meatus. JP. Fraiik reports a remarkable case of a 
patient who was obliged to sneeze one hundred times or more at every 
paroxysm. Nervous children may be seized with general convulsions 
during these paroxysms of cough. 

Vomiting usually forms the Ji?iale of every paroxysm, which, at the 
beginning of this second stage, only results in the expulsion of a little 
mucus, while much liquid food and gastric juice are thrown up. The 
longer the whooping-cough has lasted, and the nearer it approaches to 
the third stage, the more jDrofase becomes the secretion from the 
bronchi, and, finally, with every paroxysm of cough, partly by the act 
of coughing, and partly by the act of vomiting, a large quantity of 
colorless, tenacious mucus is expectorated. 

When the attacks are of much duration, protracted for ten to fif- 
teen minutes, the children feel very much exhausted after them, com- 
plain of pain in the breast, breathe for a long time anxiously and 
hurriedly, and, finally, i'all asleep. Generally, however, when the 
paroxysms are only moderately severe, they forget their sufi'erings 
immediately after they have ceased, and, to the great surprise of their 
inexperienced parents, resume their play, or even their meals. Sim- 
ple pertussis is unattended by fever, but the supervention of fever 
and anorexia always indicates a complication. 

The number of paroxysms in the twenty-four hours varies from 
four to sixty ; generally, however, not more than eighteen to twenty- 



DISEASES OF THE RESPIRATORY ORGANS. 321 

four occur during that period. No regularity in the successions, nor 
equality in their intervals, is ever to be observed. They are more 
violent, and occur oftener in the evening, when, generally, various ex- 
ternal exciting causes, such as heating, mental excitement, eating and 
drinking, co5perate. The attacks come on either wholly sponta- 
neously in children who maintain a perfectly quiet attitude, or they are 
induced by crying, mental excitements of all kinds, laughing, swal- 
lowing, particularly the swallowing of dry, irritating morsels, cold 
or impure air, etc. When several children affected with whooping- 
cough are together, and one of them begins to cough, the mere sight 
will, in most instances, infect the rest, and soon all join in this most 
distressing concert. 

In healthy children, and imder favorable circumstances, this stadium 
lasts four weeks, but it may, under other circumstances, be prolonged 
for eight weeks, or more. A remission in the severity and frequency 
of the paroxysms, attended by an augmentation of the secretion, in- 
dicates a speedy transition to the third stage. 

dd JStadkim. In this stadium criticum^ s. decrementi^ the parox- 
ysms of cough have lost their severity. The paroxysms are not so 
long, and the acts of coughing not so rapid ; the " reprise " ceases 
entirely, and, although retchings may still be present, no liquid food 
is vomited, the vomited matter consisting of an enormous quantity of 
bronchial mucus. This mucus is mostly yellowish or greenish colored, 
and, with every attack of coughing, nearly a tablespoonful is expec- 
torated. About this time nocturnal perspirations become superadded 
in most of the children, and sometimes an eczema also breaks out. In 
healthy children, when the cough has reached this stage, it will cease 
completely in from two to three weeks, but in tuberculous and scrof- 
ulous children, on the contrary, it may still last for many weeks. In 
this stage, short relapses often also occur, and the patient is thrown 
back into the second stage ; but, generally, these relapses are of short 
duration. 

The complications of this disease are numerous, and, generally, 
they are of a dangerous character. 

The most frequent complication liable to occur is an affection of 
the pulmonary parenchyma, which may very readily become developed 
from the retention and decomposition of large quantities of bronchial 
mucus. It usually appears as a lobular pneumonia, only exceptionally 
as lobar pneumonia, and is to be dreaded in proportion to the age 
of the child at which it occurs — the younger, the more dangerous. 
Children under one year of age, who lie much upon the back, and have 
not muscular ability to properly cough up the mucus from the bronchi, 
are extremely often attacked during pertussis with symptoms of 
21 



322 DISEASES OF CHILDREN. 

pneumonia, such as liot skin, rapid pulse, frequent, painful breatMng, 
accompanied by a loud noise during expiration, and elevation of the 
alge nasi. The paroxysms lose their characteristics, and a dry cough, 
combined with a painful distortion of the countenance, supervenes. 
Most of these children perish in a few days of convulsions and marked 
cyanosis. In a few solitary instances only do the sjanptoms of the lob- 
ular pneumonia subside and give place to the former pertussis, and, even 
when this occurs, there is always still the greatest danger of relapses. 

Other children suffer from gastric complications. They get a 
coated tongue, anorexia, fever, suffer from general debility, and 
putrid smell of the f^ces. The ulceration of the freenum linguse, long 
known in Germany, is a very peculiar occurrence. Gainbarini^ of 
Mailand, has lately recalled the attention of the profession to it. The 
ulcer almost always extends in a transverse direction to the long axis 
of the froenum, and very often is seen in whooping-cough in children of 
from one to two years of age, never in very young children and seldom 
in older ones. It seems that this condition depends upon a mechani- 
cal cause; namely, the tongue, in the \'iolent acts of coughing, is thrust 
out forcibly, and the fraenum is, so to speak, sawn off by the sharp 
lower incisor teeth. Hence the reason why it is never met with in 
the still toothless infant nor in older children who have already some- 
what blunted their incisors, and who are not in the habit of thrusting 
out the tongue during the attacks. It is, however, absent in a large 
nmnber of severe cases of whooping-cough, and is also observed in 
children with simple bronchitis, as well as in those without any 
cough, in the form of aphthous ulceration, especially during dentition. 
This ulcer does not heal, no matter what treatment be adopted, so 
long as the convulsive cough lasts, but will heal spontaneously as 
soon as a mitigation in its intensity has taken place. 

Again, in other children, marked cerebral symptoms supervene in 
consequence of the venous stasis ; in general, however, this compHca- 
tion is much less frequently observed. The children become lethargic, 
frequently carry their hands to the head, complain of severe head- 
ache, and other similar signs, which appear to render the pertussis a 
secondary affair. Grating of the teeth, hydrocephahc vomiting, con- 
vulsions, and coma, finally set in, though death but extremely rarely 
ensues, and when it does there is found a cerebral disease, acute hy- 
drocephalus or purulent meningitis, but which is not directly con- 
nected with the pertussis. 

Other though rare complications are pleurisy, pericarditis, and 
pemphigus. Jadelot saw joemphigoid vesicles occur in numerous epi- 
demics, and m every instance death resulted. 



DISEASES OF THE RESPIRATORY ORGANS. 323 

TI18 most frequent sequelee are chronic bronchitis, goitre, hernia, 
prolapsus of the rectum, dropsy, tuberculosis, and aneurism. 

Death, as the direct consequence of an attack, is extremely rare, and 
notwithstanding the numerous severe epidemics that I have witnessed 
I am unable to recollect a single mstance. On the other hand, the ma- 
jority of the patients affected with pneumonia died, and children under 
one year of age may, even without the superaddition of an acute 
fever, become so atrophic from pertussis as not to be able to rally. 

A"\Tiooping-cough has no power to protect its subjects from any 
other epidemic disease. Pertussis patients may acquire all possible 
diseases, acute exanthemata, intermittent fever, typhus fever, cholera, 
etc. ; but occasionally chronic skin-disease disappears in a very re- 
markable manner while the whooping-cough lasts. 

The diagnosis of whooping-cough is very easy to make. The 
cyclical course, the peculiar cough, with the prolonged, loud inspira- 
tion, the vomiting at the close of the paroxysm, and particularly the 
epidemic occurrence, as well as its often demonstrable contagiousness, 
are such constant symptoms, that their presence leads with certainty 
to the diagnosis. Moreover, a paroxysm may be induced at will in 
every child with whooping-cough, by pressing the root of the tongue 
with the finger, a fact which is often very advantageous for clinical 
purples. The retching thus produced is almost always followed by 
a violent paroxysm of cough, which instantly indicates the true diag- 
nosis where the descriptions of attendants have given no clew to it. 

Pathological Anatomy. — When an apparently healthy child with 
whooping-cough dies in consequence of an injury or some acute dis- 
ease, in the convulsive stage, the air-passages will sometimes be 
found injected, but sometimes again perfectly normal ; but, if death 
occur during the last stage, the trachea and large bronchi are filled 
with that mucus which during life was expectorated in such large 
quantities. Not the least morbid alteration is to be detected about 
the glottis. 

The bronchial glands are sometimes, but by no means invariably, 
swollen. Owing to the supposition, which prevailed for a long time, 
that a neurosis was the cause of this disease, the brain and spinal 
cord, as well as the pneumogastric nerves, were often subjected to a 
thorough examination, but this, in the majority of the cases, proved 
to be perfectly fruitless, and onl}^ a few investigators speak of a red- 
ness of the pneumogastric, which most probably is to be regarded as 
Q. post-mortem imbibition, for, on account of the rarity of the condi- 
tion, it cannot be regarded as pointing to the cause of pertussis. 



324: DISEASES OF CHILDREN^. 

The most frequent consecutive effects found are lobular and lobar 
pneumonia, cylindrical dilatation of the bronchi, partial pulmonary 
emphysema, pleuritis, pericarditis, meningitis, and tuberculosis of the 
pulmonary and bronchial glands. 

Etiology. — Whooping-cough is contagious, and attacks an indi- 
vidual hut once. The contagiousness of a disease becomes evident 
when a great number of cases follow from direct contact with persons 
affected. This has so often happened in pertussis as to establish the 
fact, and therefore it is very wrong to attempt, by single cases in 
which no contact with whooping-cough could be proved, to maintain 
a spontaneous origin for the affection. Indeed, we do not know whether 
the contagion be not so intense as to be transmittible by a third 
person, an adult, for example, himself remaining perfectly well. The 
mild and feverless character and the long duration of the disease, 
in consequence of which the sick children are much upon the streets 
and in public places, favor contact and communication more than is 
the case in any other contagious disease. Most experienced and 
reputable physicians express themselves emphatically, that genu- 
ine pertussis attacks children only once. The assertion of a few others, 
who claim to have observed it twice in the same person, is probably 
founded upon the circumstance that some tuberculous patients suffer 
from pertussis-like paroxysms, or perhaps they have met with a case 
that, already in its decline, has suffered a relapse. 

This contagious property, and the immunity following ther^rom, 
result in rendering whoojDing-cough almost exclusively a disease of 
childhood. It very rarely occurs in adults, and then mainly among 
the wealthy, who have always been much separated from children, and 
have thus escaped infection. Nevertheless, parents of children with 
whooping-cough, and the nursery-maid, frequently suffer from a 
milder kind of spasmodic cough, which seems to be due to their being 
with the patient, for these persons often are not the least predisposed 
to a cough, and lose it as soon as they have absented themselves for 
some time from the infected atmosphere. Infants before the com- 
mencement of dentition are less susceptible than those several months 
older ; still, exceptional instances of perfect whooping-cough occur in 
the former, which usually becomes comphcated with lobular pneumo- 
nia and terminates fatally. 

It is not possible to state with certainty of what kind its con- 
tagious principle is. ]\Iost probably it is confined to the particles 
of mucus expectorated, which, becoming dry, are diffused in the sur- 
rounding atmosphere, a supposition that also seems to be borne out 
by exjDerience, for, in the last stage, children infect with greater cer- 
tainty. 



DISEASES OF THE RESPIRATORY ORGANS. 325 

The stage of incubation lasts but a short time, barely ever more 
than three or four days. 

In addition, its purely nervous contagious character, induced by 
simple imitation, as are gaping, vomiting, chorea, hysterical convul- 
sions, etc., may deserve attention. The constitution, the manner of 
living, and the season of the year, have no marked influence upon the 
origin or prevention of the disease. 

By its contagiousness, then, the epidemic propagation of pertussis 
is brought about, so that in the course of a quarter, or at the most 
half of a year, the entire juvenile population, or, at least, the greater 
portion of it, has been infected by this disease. Schools and chil- 
dren's hospitals are to be regarded as the most prolific channels for 
its propagation. In the latter institutions in particular, it will often 
rage for years, after it has died out in the cities, for new children are 
constantly admitted for surgical or other internal diseases, and then 
acquire pertussis. 

Treatment, — The prophylaxis consists entirely in the removal of 
the children from the place in which whooping-cough is just appearing, 
for a perfect isolation is only carried out with the greatest difficulty, 
and never affords as good a guarantee as an actual change of place 
does. Jeyiner made the interesting observation, that children recently 
vaccinated escaped whooping-cough, and that vaccination exercised a 
favorable abortive influence on patients. Owing to the circumstance 
that we usually perform vaccination in the first months of life, and 
that young children are less Hable to sicken with pertussis than those 
that are a year or more old, the contingency in which this prophylaxis 
is apphcable is a limited one. I have as yet vaccinated only two 
young patients with pertussis, one of which was sick for two, the 
other for three weeks : in both the course was a regular one ; in the 
first the actual paroxysms lasted ten, in the second seven days, so 
that, if six weeks were calculated as requisite for the full course, then 
quite an abbreviation of the process was effected here. The internal 
administration of belladonna^ and the suspending from the neck of 
small bags containing various kinds of strong aromatic substances, 
moschus, camphor, etc., have long ago proved to be totally useless as 
prophylactic measures. 

The rational treatment of the established disease consists in the 
prescribing of an appropriate regimen, in treating the individual 
paroxysms, and in the attempt, by the aid of proper remedies, to bring- 
about an abbreviation of the entire process. 

As regards the manner of living, that depends upon the season of 
the year. In winter and during the prevalence of sharp, roug'h 
winds, the permitting children with whooping-cough to go out is 



326 DISEASES OF CHILDEEN. 

always hazardous, and often results in inflammatory complications ; in 
summer, on tiie contrary, the subjects are most comfortable through 
the day when they are out in the free air. The course of whooping- 
cough in winter, where children are for many weeks confined to 
the house the entire day, and at the most are only able to go out for 
an hour on a warm noonday, is therefore slower, and oftener leaves 
sequelge than in summer. 

As regards the diet, so long as the process runs a simple, fever- 
less course, no changes need be made, but dry bread and cake, and 
all kinds of dry irritating nutriments in general, are to be prohibited, 
because, in their passage over the epiglottis, they infallibly induce a 
paroxysm. "When febrile complications become superadded, an an- 
tiphlogistic treatment is called for, and its character is abeady under- 
stood. Milk nutriments, and a plentiful supply of lukewarm milk, 
exercise a favorable influence in this disease, while the so-highly- 
recommended althaea and elder-flower teas are totally despised by 
most children. 

Concerning the so-much-lauded change of air, a residence in the 
country does not by any means possess that abortive influence that is 
usually attributed to it ; still, sometimes it works quite surprisingly 
when the patients are removed to the country in the last stage of 
whooping-cough, say, in the fourth or fifth week. The great joy at- 
tendant upon the change of place, the altered diet and manner of 
living, seem to at once arrest all signs of the disease, and from that 
time the children are not heard to cough. 

But, when children who have only just contracted pertussis are 
sent into the country, no alteration nor abbreviation whatever is to be 
observed ; they infect the children of the village, who may die of 
lobular pneumonia, and thus bring about most unpleasant conse- 
quences. 

As regards the paroxysms, all exciting causes are most scrupu- 
lously to be avoided. The children should be commanded to eat 
slowly and quietly, they should not run nor become heated, and are 
to be spared all mental disturbances so far as it is possible. As the 
witnessing of a paroxysm will also immediately induce one in a child 
suffering from whooping-cough, it is therefore advantageous to sep- 
arate such children whenever it is possible. 

In the paroxysm itself the child is easiest with the neck flexed 
sHghtly forward, and the hands grasping firmly some stable support. 
In case the child droops its head too far do^vnward, the forehead should 
be supported by the hand. Occasionally very severe and prolonged 
paroxysms may be cut short by introducing the finger far into the 
mouth, and thereby inducing premature vomiting. Churchill advises 



DISEASES OF THE EESPIRATORY ORGANS. 327 

that, at the beginning of the attack, half a drachm of ether or chloro- 
form be poured into the hollow of the hand, and held in front of the 
child's face. I have tried this only once, but the child was decidedly 
averse to the vapors, and the room smelt so strongly of chloroform 
the whole day that its occupants were affected with headache, and 
opposed to its further employment. If, at the end of a paroxysm, slight 
giddiness and stupor ensue, the children will be obliged to lie down 
for some time, and the head should be covered with cold compresses. 

To enumerate all the remedies that have been resorted to in whoop- 
ing-cough would consume too much space, and be of little benefit, for 
it is now a conceded fact that remedies, whifch were found to be of 
decided value in some epidemics, proved totally worthless in others. 

The treatment by emetics has been, and still is, most incompre- 
hensibly, much in favor. Emetics were given every day, or, at least, 
every other day, for one or two weeks, and it was believed that an 
abbreviation and mitigation of the attacks were effected. To young 
children the French physicians give their syr. ipecac, to the older 
ones vin. stibiat. The fact that those who extol these therapeutic 
experiments are now very materially reduced in numbers, would, of 
itself, dissuade me from repeating them. And, besides, to induce 
vomiting artificially in a disease which is attended by recurring acts 
of vomiting is, as it seems to me, to say the least, entirely super- 
fluous. 

Of the narcotics, helladonna came in use by preference, and of 
this remedy, in particular, has it oftenest and most strikingly been 
observed, that its effectiveness is decidedly different in different epi- 
demics. Thus, J. FranTi^ for example, in one epidemic, derived bene- 
ficial effects from it, in six others none whatever. I myself can only 
find fault with belladonna for the inequality of its preparations, on 
account of which it is necessary to exercise the utmost possible cau- 
tion in increasing the dose. As soon as dilatation of the pupils and 
irritation of the throat ensue, the paroxysms, it is true, become de- 
cidedly ameliorated; but these symptoms of poisoning are also of 
themselves unpleasant. They frighten the parents, and in some chil- 
dren, even when the use of the remedy has been suspended, complete 
blindness, giddiness, and critical delirium, appear. 

So long as the pupils remained undilated, I have never yet been 
able to detect any mitigation in the paroxysms. The medium dose is 
rad, helladonna gr. -J twice daily, in the form of a powder. As 
many children do not readily take powders, it is best to employ a 
mixture of ext. helladonna^ gr. ij — iv, dissolved in 3 ss of hitter- 
almond water^ of which twenty drops may be given two or three 
times daily. The reproach of uncertainty of action, supposed to 



328 DISEASES OF CHILDREN. 

depend upon the manner of preserving belladonna, is even more 
applicable to the extract than to the powder. In its entire course 
whooping-cough cannot be cut short by belladonna, and a mitigation 
of the individual paroxysms can only be accomplished through a 
poisoning, at the risk of unpleasant consecutive effects. 

Opium has been repeatedly recommended. And what was said 
of belladonna is also applicable to this remedy, only in a still greater 
measure. When given for some time it produces constipation, diffi- 
cult to be overcome, and cerebral congestion. Still, at the climax of 
the disease, when the child has already passed several sleepless nights 
and is extremely excitable, it is a very valuable remedy. One to five 
drops of laudanum, according to the age of the child, to be sure, pro- 
duce several hours of sleep, after which, however, the paroxysms re- 
commence with their former severity. 

Some physicians, in addition, extol ext. conii^ hyoscyami, lactucm 
virosce^ pulsatilloe^ nicotiance and aq. ainygdal. amar., which are 
rejected by others. In those whooping-cough epidemics which I have 
so far had an opportunity to witness, I have repeatedly observed that 
the continued use of narcotics for several days, in the early part of 
the disease, only caused harm, while, at its climax, a single or 
repeated narcotism, with opium or belladonna, exercised a favorable 
influence upon the exhausted and yet excitable children. 

The opposers of these narcotics recommend the onetalUc antispas- 
modics. Their extoUers very naively say that, with them, a rapid 
mitigation of the violent cough is less surely effected than a gradual 
extinction of the convulsive character is achieved, and then only is a 
cure effected ; or, in other words, whooping-cough cannot be hindered 
much in its regular course by these remedies. Of this class the most 
preferred remedy is zinci oxidat. 3ss — 3j, pro die; next, carbonate 
of iron, 3] — 3ij pro die; acetate of lead ^ nitrate of 'bismuth, sulphate 
of copper, and, lastly, nitrate of silver. 

The most frequently employed vegetable and anitnal nervines are 
moschus, castor eum, assafoetida, succinate of ammonia, and lastly coffee. 

Tonic and astringent remedies are of decided benefit in the last 
stage of pertussis, and here the powdered cinchona bark is superior 
to all the rest. In this stage I give to very many feeble children as 
much of the powder as can be taken upon the point of a common 
table-knife two or three times daily, without any admixture whatever, 
and find that they take it without much objection, and for that reason 
employ it in preference to the decoction, and the altogether too-bitter 
quinine. Also tannin, by itself, or in equal parts with the flowers of 



DISEASES OF THE RESPIKATORY ORGANS. 329 

benzoin, given as high as five grains a day, is much praised by some 
physicians. The equally-bad taste, and especially the constipating 
effects that invariably result from its repeated employment, are the 
great objections to it. 

Cochineal, a purely empirical remedy, is tolerably extensively used 
by English practitioners, who, according to perfectly reliable reports, 
claim to have produced some very remarkable effects by it in some 
epidemics. On account of its being easily decomposed, it is best to 
give it in powder mixed with a little sugar, two to six grains pro die. 
My experiments, performed with it in two epidemics, furnished en- 
tirely negative results, and, owing also to the article being somewhat 
expensive, I have now abandoned it altogether. During the last two 
years, I have made somewhat extensive use of a remedy that has 
fallen into much disrepute, namely, calomel. I give it daily to all 
whooping-cough patients, under one year of age, in doses of one-eighth 
of a grain for two or three weeks, until the severity of the parox- 
ysms diminishes. Since that time I have observed a far less number 
of cases of lobular pneumonia, which previously carried off a consider- 
able number of the infants. Consecutive effects, whether immediately 
or later, do not ensue from this treatment. 

The rest of the empirical internal remedies to be mentioned are, sul- 
phur^ lobelia inflata^ viscum quercinum, muriatic acid / and, lastly, 
arsenic, phos2:>horus, and tr. cantharidis. 

The endermic treatment with ung. tartar, stihiat, is now com- 
pletely abandoned, as cruel and ineffectual. JLachmanrCs method, on 
the contrary, seems to deserve a further trial. He claims that, in the 
first stage, whooping-cough may abort by vaccination, and, in al- 
ready-vaccinated children, strews the powder of a vaccine crust 
upon a blistered surface, where it is confined for several days by 
adhesive plaster. It is asserted that blisters treated in this manner 
cause severe pain, and occasionally even become gangrenous. He 
also administers the powder internally, a vaccine crust being rubbed 
up with sugar of milk, and repeats this dose after four days, 
by which treatment equally rapid cures are claimed to have been 
achieved. 

Lastly, there remains yet to be mentioned, Watsori^s repeated and 
laborious cauterizations of the mucous membrane of the fauces and lar- 
ynx with a solution of nitrate of silver, by which it is claimed that the 
affection is subdued in from eight to ten days. With us, they have 
not proved themselves of such decided efficiency as to have obtained 
general recognition. 



330 DISEASES OF CHILDREN. 

If now, as a 7'esume, I were to give an explanation of my views, it 
would go to show tliat there never has been, and most probably 
never will be, a remedy by which whooping-cough may be abridged, 
any more than we are able to cut short the acute exanthemata, or ty- 
phus fever, or pneumonia. Hence, an expectant treatment is to be 
continued as long as possible ; the violent paroxysms should be pal- 
liated by narcotics ; lobular pneumonia in infants we must try to pre- 
vent by small doses of calomel ; feeble children are to be treated with 
tonics, and, as a general rule, all the patients should be kept under the 
most favorable hygienic conditions possible. 

(12.) Peeiodic Noctue:n-ai. Cough.— Periodic night-cough is an 
extremely rare and peculiar disease. It is observed in perfectly healthy 
children, but oftener in those vrith hereditary tuberculosis, and usually 
attacks children from two to ten years of age. 

Throughout the entire day, the child does not cough, sleeps tran- 
quilly in the evening, and, as a rule, wakes up only after midnight, 
crying violently, and coughing. Generally, the cough is continuous 
and dry, not so paroxysmal as to give rise to dyspnoea as in whooping- 
cough, but severe enough to prevent sleep for two or three hours 
every night. It is not accompanied by expectoration, and the 
character of the cough is best compared with that of an hysterical 
girl, who sometimes suffers from paroxysms of a purely spasmodic 
cough. This cough recurs every night, not precisely at, but about 
the same hour, every paroxysm lasting an equally long period, 
until finally the child, entirely exhausted, and breathing rapidly, 
falls asleep, to wake no more tiU morning. Thus it goes on for 
weeks, a.nd even months, the attacks finally becoming shorter and 
feebler, and ultimately ceasing entirely. The eruption of a tooth of the 
first or second dentition often forms the final act of this enigmatical 
disease. I have met with it but three times ; one child, both pre- 
viously and subsequently to the attack, was perfectly v/ell, but the 
other two were the progeny of tuberculous parents, and subsequently 
exhibited very distinctly the signs of progressive tuberculosis. Al- 
though the cough in the daytime ceases completely, and no sibilant 
rales whatever can be heard over the entire thorax, nevertheless, dur- 
ing the whole day, the children are gloomy, morose, and become anae- 
mic. They have not a proper appetite, and mostly suffer from cold 
feet. 

Treatment. — The distinct intermissions which mark the course of 
the disease seem to indicate a treatment with quinine. But, notwith- 
standing this circumstance, this remedy has proved itself totally use- 
less, the cough in most instances recurring, even when large doses, 



DISEASES OF THE EESPIRATORY ORGANS. 331 

from four to six grains, are administered at a time. Small doses of 
narcotics are quite as unsatisfactory. Opium and morpliine, given to 
produce profound narcotism, do indeed bring about an arrest of the 
malady for one night, but the attending bad effects of large doses 
— ^loss of appetite, headache, and obstinate constipation — are so un- 
pleasant, that I have always been compelled to desist from a continu- 
ous administration of these remedies, before obtaining any perma- 
nent result. The ineflficacy of quinine and morphine proclaims with 
tolerable emphasis that a material alteration — to be sought for, per- 
haps, in a swelling or tuberculosis of the bronchial glands — must be 
at the bottom of this disease. It is best to limit the treatment to a 
good diet and tonics, fresh air, and uniform temperature, with which, 
according to the experience so far acquired, the malady has always, 
although after a very long time, terminated favorably. 

Y.— PLEURA. 

(1.) Pleueisy {Pleuritis). — Pleurisy may even attack children in 
utero, who then as a rule perish, or survive the delivery but a short 
time. In the new-born child, phlebitis umbilicalis is a frequent cause 
of puiTilent absorption, and thus also of secondary pleurisy. 

Empyema occurs so rarely in early infancy that the most expe- 
rienced Psediatricars have only been able to report a few solitary in- 
stances. On the other hand, general pleuritic adhesions are often 
found in young children, who, during life, suffered from pulmonary 
affections, particularly from phthisis pxilmonalis. In older children 
empyema occurs not infrequently, becomes, when no complications 
are present, tolerably quickly absorbed, and leaves behind it no re- 
markable deformity of the thorax. Altogether, pleurisy in the first 
age of childhood may be regarded as an extraordinarily rare affection, 
and as a tolerably infrequent one after the beginning of the second 
dentition. 

Pathological Anatomy. — According to F. Weber, of Kiel, to 
whom we are indebted for most of our knowledge concerning this 
condition, the profuse transudation of bloody serum into the large 
serous sacs, and consequently also into the pleural cavities, is to be 
accurately distinguished from the genuine pleurisy of still-born chil- 
dren. No flakes of fibrin are ever found in that simple cadaveric 
transudation, nor has the mother during her pregnancy experienced 
any symptoms referable to that condition. In these still-born children, 
TFe^er assumes 2, purely inflammatory and a dyscrasic pleuritis. 

In purely inflammatory pleurisy of children before birth, the cor- 



332 DISEASES OF CHILDREN, 

responding lung, in most instances, is also affected. The pleurisy is 
unilateral or bilateral, and is seen as a thick or thin, fibrinous, whit- 
ish, transparent layer, which sometimes is easily, and other times 
again with difficulty, pulled off. The serous effusion is here always 
insignificant, yellow, and clear, and entirely different from the cachec- 
tic, never putrid, and never very strongly tinged with blood. 

In dyscrasic pleurisy^ both pleural sacs, and, in addition, gen- 
erally also the pericardium and peritonaeum, are simultaneously affect- 
ed. The exudations are present in larger quantities than in the pre- 
ceding form, and have a dirty, opaque appearance, and a putrid smell. 
This form occurs only in lying-in-hospitals, and at the climax of epi- 
demics of puerperal fever. Pyasmic pleuritis, occurring as a result of 
umbilical phlebitis, also has the same characters. 

In older children, pleuritic adhesions and layers of false mem- 
brane are very frequently observed; very seldom, however, large 
effusions. These inflammatory affections of the pleura but very rare- 
ly occur primarily and in an isolated form, but are always complicated 
with disease of the lungs and with tuberculosis. The morbid forma- 
tion of false membranes, the displacement of the thoracic viscera, and 
of the diaphragm, are similar to those which take place in the adult. 

Symptoms. — Every pleuritis begins with fever. The child be- 
comes restless, sleepless, loses its appetite, and suffers thirst. The 
most distinct sign of fever is always an increase in the temperature 
of the skin over the entire body ; whereas the frequency of the pulse, 
^particularly in infants, deserves less consideration on account of its 
great physiological fluctuations. Older children suffer also from a 
chill. 

» 
In young children the pain can only be elicited by exercising an 

alternate pressure upon various parts of the thorax, or by percussion. 
Pressure or a blow upon a part freshly attacked by pleurisy always 
causes the child to utter a cry or moan of pain. Somewhat older chil- 
dren, two or three years of age, when questioned concerning the site 
of the pain, point to the prascordia, though there be no signs of dis- 
ease there. To the statement of children under five or six years old, 
as to the locality of pain, no value can be attached. Generally, it 
comes on simultaneously with the fever, but hardly ever is of long du- 
ration, exhibits very distinct remissions, and, after four to six days, 
often disappears entirely, even without any remedies having been 
employed. 

In general, it may certainly be said that the fever and the pain 
progress pretty regularly together, still, very frequent exceptions occur 



DISEASES OF THE KESPIRATORY ORGANS. 333 

to tliis rule. Tlie sudden recurrence of a pain that has been ab- 
sent for several days deserves particular consideration, especially if 
it is attended by fever ; for it then indicates that the pleuritis is not 
simple, but a complicated one, and pulmonary tuberculosis may be 
stated to be the most frequent complication of, or rather cause for the 
appearance of such symptoms. The pain also exercises great influ- 
ence upon the degree of the dyspnoea, which at first is much more 
aggravated by it than by the mechanical impediment, the effusion. 
As soon as the dulness becomes considerable, the effusion conse- 
quently having become greater, the pain, in most instances, vanishes 
altogether, and in its place the mechanical embarrassment, produced 
by the compression of the lungSy ensues. Why the pain is often con- 
fined to one spot only, notwithstanding the great extent of the pleu- 
risy, is difficult to explain. The most plausible supposition, it seems 
to me, is, that the inflammation, in some part, implicates the neu- 
rilemma of the intercostal nerves, and thus the circumscribed, fixed 
pain, violently aggravated on pressure, is produced. 

The decubitus in young children, who, in general, lie on the 
back, naturally has no great significance ; but older children, at the 
invasion of the pleurisy, as a rule, lie, as long as the pain exists, upon 
one side, but not always upon the one corresponding to the pain. 
This seems to depend upon whether the pain is aggravated more by 
the pressure, or by the acts of respiration. In the first case, they lie 
upon the sound side ; in the second, upon the affected one ; for, 
in this later decubitus, the acts of respiration become smaller in a 
purely mechanical manner, without any special effort on the part of 
the patient. 

The acts of respiration vary in hind and number according to the 
pain and fever. The more intense these two symptoms are, the more 
rapid and superficially do the children breathe. On the other hand, the 
effusion, after the acute process has ceased, is seldom so bulky as to 
keep up a continuous acceleration of the respiration. In form, the 
accelerated breathing is that of the expiratory, i. e., the accent lies 
upon the expiratory sound. No actual dyspnoea is present, but the 
respirations are frequent and superficial, in order that the deeper and 
painful ones may be avoided. For the same reason the movements 
of the alas nasi are also less marked than in parenchymatous disease 
of the lungs, for example, in pneumonia, or advanced tuberculosis. 

By inspection it is not possible to ascertain upon which side the 
pleurisy is situated, so long as there is only a pleuritic membranous 



334 DISEASES OF CHILDREN. 

exudation, and no bulky liquid effusion. But, wlien the latter has 
formed, the intercostal spaces become obliterated and bulge outward, 
and all those ribs which are separated from the corresponding part of the 
lung by the fluid effusion remain stationary. Then, mensuration of 
both thoracic halves also furnishes a larger circumference for the 
affected side. In lean children, a sinking of the liver, in right uni- 
lateral effusions, is seen, and, in left unilateral effusions, a displacement 
of the heart toward the xyphoid cartilage, and even beyond it. 

Pleuritic effusions may very readily and accurately be diagnosti- 
cated hj 2^cd2^cition of the vocal fremitus, and, in children, this method 
of examination is of the greatest value, as it can be practised in 
restless, crying children. So far as the fluid exudation reaches, no, 
or but a feeble, fremitus of the voice is to be felt, while it is felt at the 
same time stronger over the rest of the thorax. Friction-sounds are 
extremely rarely met with in children at the beginning of pleurisy. 
They are somewhat more frequently heard in an empyema undergoing 
absorption, and are generally found at the place of transition from dull 
percussion to sonorous sound. Indeed, it is even possible to detect 
them by palpation alone, but, by palpation, it is very easy for one to 
be deceived by simultaneously-occurring sibilant rales. In quiet, sen- 
sible children, this physical method of examination may readily be 
completed by auscultation. At the commencement of a pleurisy, 
either friction-sound or normal vesicular breathing is heard, provided 
the lungs have not been previously affected. In most cases nothing 
whatever is to be heard after the fluid effusion has separated the lung 
from the ribs; sometimes, however, very unexpectedly, and with- 
out our having been able until then to obtain a special explanation, 
well-marked bronchial respiration is heard, but which lasts only for a 
few days, and then totally disappears. But when the exudation be- 
comes so large in quantity that the lung of the affected side is wholly 
compressed and pushed backward into a sohd compact mass, not puerile, 
but bronchial breathing will be heard upon the dorsum of the thorax 
as far as the airless lung extends. As the absorption of the emjDyema 
progresses, the lung dilates, the bronchial breathing disappears, sibilant 
rales often come on, or the normal vesicular breathing is again heard. 

Percussion supplies positive results in very extensive fluid efiusions 
only ; compact pleuritic exudations, and, still less, simple pleuritic ad- 
hesions, effect no alteration whatever in the percussion-sound. But, 
when pleuritic effusions have actually taken place, we have a far 
more distinct dulness than in solidification of the pulmonary tissue ; 
we get a completely flat sound (the so-called thigh or wall sound). 



DISEASES OF THE RESPIRATORY ORGANS. 335 

On tlie margin of the dulness, a tympanitic sound is invariably heard, 
which extends itself for some distance into the sonorous sound. 

If at any time a large quantity of purulent effusion had accumu- 
lated in one of the pleural sacs, and subsequently become absorbed, a 
condition that is almost exclusively met with in children several years 
old appears. The behavior of the pleura after the absorption of the 
empyemic fluid, so strikingly observed in adults, soon becomes mani- 
fest. On the affected side the shoulder is depressed, the nates some- 
what elevated, the entire pectoral half flattened and contracted, 
strongest between the fifth and eighth ribs, and the spinal column 
sufi'ers a lateral curving, the concavity of which is directed toward the 
affected, the convexity toward the healthy side. A compensatory 
curvature of the lumbar vertebra is, of course, also present. As the 
patients progress in recovery, and become invigorated, these distor- 
tions disappear almost completely in a few years, which is very much 
facilitated by an appropriate gymnastic training. 

Spontaneous perforation of the thoracic walls, and evacuation of its 
contents outwardly, occur oftener in empyema of children than in that 
of adults. An erysipelatous erythema, attended by fever and lanci- 
nating pains, appears on some part of the thorax, most frequently on 
its anterior part, under the nipple ; the corresponding intercostal space 
bulges more and more, fluctuation at length becomes more distinct, 
and, finally, there forms a circumscribed oval swelling, which bursts 
spontaneously, or may be opened with a lancet without any danger. 
At first a large quantity of pus is evacuated, but soon the abscess con- 
tracts, and is converted into an oblique, angular, fistulous passage, 
which frequently closes, but after a while is again attacked by inflam- 
mation, and breaks open anew. Such a fistulous canal will remain 
open for months, and even years, according to the condition and dis- 
tensibility of the corresponding lung, and ultimately closes with a 
radiating, contracted, deep-pitted cicatrix. Caries of the ribs, not- 
withstanding the long duration of the process, scarcely ever occurs. 

The complications of pleuritis are numerous. First of all, the 
various general diseases, in the course of which pleurisy may become 
developed, are to be mentioned. Thus, it occurs in scarlatina, measles, 
small-pox, typhus fever, pyasmia, and scorbutus. The frequency 
of these complications varies according to particular epidemics. 
Pleurisy is most unfavorable and dangerous when it supervenes early 
on a general disease, while that occurring during convalescence compar- 
atively often takes a favorable course. Pleurisy, as a result of pyemia 
and scorbutus, is, naturally and unexceptionally, fatal. 

Pleuritis very often is a secondary disease of tuberculosis and 



336 DISEASES OF CHILDREN. 

pneumonia. In fact, there is no peripheral morbid alteration of the 
pulmonary parenchyma in which the pleura does not participate. Al- 
though the ordinary form is that of simple adhesions, or, at the most, 
of narrow pleuritic membranes, still, quite extensive effusions not in- 
frequently occur, especially in tuberculous children. They are scarcely 
ever simply purulent, but metamorphose even into the tuberculous. 
The entire pleura, surrounding the exudation, is converted into a yel- 
low, granular, tuberculous membrane, and no absorption of any such 
exudation has yet been observed. Perforation of a tubercular lung 
into the* pleural cavity and pyo-pneumothorax, as a result of the more 
acute course of tubercles in children, rarely occurs. 

The course and termination are variable. Acute primary pleurisy, 
as it sometimes attacks healthy older children, is, notwithstanding the 
extensive effusion filling up the entire pleural sacs up to the apices 
of the lungs, not a dangerous disease. After one or two months, ab- 
sorption begins, and, if the children are in other respects healthy, is 
completed in three months. Even the habitus of the absorbed em- 
pyema that remains behind is tolerably well outgrown in the course 
of a few years. Acute secondary pleurisy, as it is observed in the 
course of acute exanthemata, of typhus fever, and of tuberculosis, is 
incomparably more dangerous, and pysemic pleuritis of the new-bom 
child is unexceptionally fatal. So also is pyo-pneumothorax, after the 
bursting of a tuberculous cavity ; but this, on the whole, is a very rare 
condition. 

Chronic pleuritidis, thin layers of false membranes or simple ad- 
hesions, such as accompany every affection of the lungs, are apt to un- 
dergo no or extremely slow absorption. The morbid alteration of 
the lungs becomes so prominent here, that the pleuritic phenomena 
very seldom attract any attention. Sacculated empyemas, which in 
the adult may exist for ten and twenty years, do not occur in children, 
in whom the more rapid development is always attended by a com- 
paratively quicker absorption. 

Treatment. — Many words need not be wasted in describing the 
therapeutics of secondary pyasmic pleurisy of the new-born child, for 
it is a fatal affection under all circumstances. Primary pleurisy of 
older children, with rapid effusion at first, is to be treated moderately 
antiphlogistically. There is no remedy by which the augmentation 
of the effusion can be certainly arrested ; it is not possible to accom- 
plish this even by the largest abstractions of blood. This remedy, 
consequently, is not admissible ; still, it cannot be denied that in older 
children, over five years of age, the severity of a pleuritic pain may be 
very much alleviated by a few leeches. In infants, the moist girdle 
alone, already described in the section on pneumonia, but which 



DISEASES OF THE RESPIRATORY ORGANS. SB7 

Las to encircle the whole thorax for from four to six days, suffices to 
mitigate the pain. 

Th^ internal treatment, so long as the fever and pain are very 
considerable, is best fomided upon the administration of small doses 
of calomel, to which small quantities of opium may very properly be 
added — 5 to ^ grain of calomel, and -Jg- to ^ grain of opium, may be 
given daily to children, three to six years old. Diarrhoea should 
never be allowed to run very long. If the pleuritic effusion has already 
ceased to increase, and has become stationary, the fever will subside 
too, and then there is no indication for the above-named remedies. 
The question that comes up for consideration is about the removal 
of the effusion in as short a time as possible. For this purpose in- 
unctions of blue and iodine ointments are resorted to. Internally the 
various diuretics are recommended. 

The alkaline diuretics, nitrate and acetate of potassa, are not adapt- 
ed to children, on account of their bad taste and drastic effects. On 
the other hand, small doses of digitalis, gtt. vj — xij pro die of the tinc- 
ture, in a two or three ounce vehicle, are very well borne, but are to 
be discontinued as soon as slowness of the pulse ensues, and re- 
peated when that passes off. But roob * juniperi is tolerated 
longest and best of all the diuretics, of which one or two teaspoonfuls 
daily may be given to the child for months. The effects of the diu- 
retics, on the whole, should not be over-estimated, for it has often 
already been observed that such simple pleuritic effusions, under 
favorable circumstances, have in a few weeks disappeared entirely, al- 
though no internal treatment had been resorted to. Proper nutrition 
and good air are the main factors for the success of a rapid absorption. 
Hospital air acts extremely injuriously upon the absorption of an em- 
pyema, and such patients are therefore to be kept as far from the 
hospitals as possible. In older children the operation of paracentesis 
thoracis has often been performed with success. I, however, have 
never yet met with a case where it was absolutely called for, and for 
that reason have never performed it. 

Twice I saw, in healthy, robust, well-developed children, a swell- 
ing arising under the mamma, one of which opened spontaneously, 
the other was opened with the lancet. In both instances a large quan- 
tity of pus escaped at first, and the lungs dilated correspondinglv. 
But the fistula which remained healed only after the lapse of years, 
and several times broke out anew. 

(2.) Hydeothokax. — In nurslings, serous effusions into the pleural 

* See note on page 223. 
22 



338 DISEASES OF CHILDREN. 

sacs occur very infrequently ; in older children, however, they are more 
frequently seen as the effects of certain diseased conditions. The fluid 
poured out is purely serous, yellow, albuminous, and the salts it con- 
tains exhibit the same quantitative proportions as those of the serum 
of the blood. On the pleura itself no morbid alterations are to be de- 
tected, if no pulmonary disease with mild pleuritis have preceded it. 

Etiology. — Some authors still assume that a primary, essential 
hydrothorax may occur, but that is extremely problematical, for some 
preceding diseases, in certain instances, are readily overlooked. Nephri- 
tis, the result of scarlatina, undoubtedly furnishes the most frequent 
cause ; next follows the intermittent-fever cachexia, and finally, as 
the rarest cause, an acquired disease of the heart is to be mentioned. 
The rest of the cachexise, through which, in the adult, hydrothorax 
may also be engendered, such as hepatic cirrhosis, chronic Bright's 
disease, carcinoma, paralysis, etc., scarcely ever occur in children. 

Symptoms. — Hydrothorax after scarlatina appears several days 
after anasarca has appeared, but by this we do not intend to say that 
it must absolutely follow in this manner. Anasarca is regularly 
ushered in by febrile phenomena, which become aggravated when 
serous effusions into the pleural and peritoneal cavities are superadded. 
The formation of the diagnosis in that case is much facilitated by the 
existence of the anasarca. 

Hydrothorax, as a result of intermittent-fever cachexia, sometimes 
occurs with, sometimes without, fever. Generally, however, anasarca 
is also present here, at least of the lower extremities. The grayish- 
yellow color of the face, the extreme anaemia of the mucous mem- 
branes, and the invariably present splenic enlargement, are such 
prominent signs as to preclude the possibility of mistaking the inter- 
mittent cachexia for any other. 

Hydrothorax in consequence of disease of the heart is the rarest 
form, because in children endocarditis occurs very infrequently, and 
generally quickly terminates fatally, and because congenital cardiac 
malformations terminate usually too early to produce dropsical effu- 
sions. 

Hydrothorax, in contradistinction to pleurisy, is much oftener ob- 
served on both sides than on one side only ; still, the quantity of the 
effusion is seldom alike on both sides. The pain in the side, so con- 
stant and persistent in pleurisy, is totally absent in hydrothorax. In 
a marked example of hydrothorax, the dulness is complete, and its 
boundaries may be changed readily by varying the position. Children, 
however, do not willingly submit to this kind of manipulation. Tlie 
fluid is so thin and copious, that it quickly changes its place in ac- 
cordance with the laws of gravity. Friction-sounds are never felt nor 



DISEASES OF THE NERVOUS SYSTEM. 339 

heard, but the external form of the thorax becomes altered as strik- 
ingly as, and perhaps still more so than, in empyema. Dilatation and 
bulging of the intercostal spaces, immobihty of the part of the thorax 
^ith which the serum is in contact, and alterations of the position of 
the heart and liver, occur here in the most striking manner. 

As hydrothorax in most instances is bilateral, the dyspnoea, there- 
fore, increases rapidly ; soon orthopnoea, cyanosis, and oedema of the 
lungs supervene, whereupon death quickly ensues. The secretion of 
urine in most instances is very much diminished ; the bowels may be 
torpid, or, as is frequently the case, a derivative attempt may have 
been made by the alimentary canal, giving rise to diarrhoea. 

The pulse at first is much accelerated, but in moderate dyspnoea 
may soon return to its normal condition. 

The prognosis may be set down as most unfavorable after scar- 
latina, not very favorable after intermittent fever, and decidedly 
unfavorable, if not positively hopeless, after cardiac disease. 

Treatment. — A debilitating, antiphlogistic treatment is never in- 
dicated here, although in the first days of the illness distinct febrile 
phenomena may have been present. The subjects always become so 
exhausted by their preceding sufferings, that it seems absolutely neces- 
sary to pay the utmost attention to the nutrition. Nourishing broths, 
with yolk of eg^ and milk, should therefore be allowed them, and as 
much as they will consume ; and an attempt is to be made by mild 
diuretics, such as will not disturb the digestion nor cause diarrhoea, 
to stimulate the kidneys and to promote the excretion of the urine. 
In this respect a few drops of the tincture of digitalis, with roob 
juniperi in large doses, as I have often stated, are the most appro- 
priate remedies. In the after-treatment, quinine and iron are most 
to be relied on. 



CHAPTER V. 

DISEASES OF THE NERVOUS SYSTEM. 
K.— BRAIN. 

(1.) Htdeocephalus Acutus Inteentjs. Synonyma, — Meningeal 
tuberculosis, morbus cerebralis Whyttii, hydrophlogosis ventricu- 
lorum cerebri (Lohstein), febris hydrocephalica. Entero-cephalopyra 
{^JEisenman^i). 

The pathology of hydrocephalus consists in a miliary tuberculosis 
of the arachnoid membrane, especially at the base of the brain — m an 



340 DISEASES OF CHILDREN. 

intense augmentation of the normal fluid contents of the cerebral 
ventricles, and in a softening of the parts of the brain entering into 
the formation of the cerebral cavities. Tuberculosis of the meninges 
is generally stated to be the exciting cause, and an acute internal 
hydrocephalus, not tubercular, is also spoken of. I have never yet 
met with this latter kind of acute dropsy of the head ; but of the for- 
mer, on the contrary, I have dissected more than fifty cases, and the 
majority of them I also observed during Hfe. 

Pathological Anatomy. — In these autopsies, the dissection of the 
skull must be performed with the utmost caution. If the large 
fontanel is not yet closed, it will be seen to bulge out enormously, 
and often a decided fluctuation may be detected over it. The skull 
should be sawn very slowly, and the movements of the saw should be 
short, especially toward the close of the operation, in order that the 
brain, which is often very soft, may not be injured, and the contents 
of the ventricles be lost before they are closely inspected. If the dura 
mater, at certain places still adheres to the bone, it will be very 
difficult to remove the calvarium, conjointly with the dense dura 
mater, without injuring the brain. In these rare cases it is advisable, 
after the skull has been sawn through, not alone to sever the dura 
mater all around, but also the brain, and then to remove the calva- 
rium, dura mater, and the whole portion of the cerebral substance 
lying above the incision, en masse, by the aid of a brain-knife or spatu- 
la. It is true that, by so doing, the ventricle is opened and its watery 
contents escape, but then we have the advantage of being able to 
examine more accurately the base of the brain, and we thereby also 
spare the rest of the generally soft, friable portion of the organ. 

After the calvarium and dura mater have been removed, the brain 
to a certain extent bulges out over the edges of the divided skull, 
the pia mater and arachnoid will be found to be very tense, the arach- 
noid membrane upon the convex part of the brain dry, and the convo- 
lutions obliterated ; it is, therefore, plain that the cerebral substance has 
been firmly compressed from Avithin outward against the bones of the 
head. That the injection of the meninges in the cadaver had no con- 
nection with the injection of the meninges during life now becomes suffi- 
ciently evident, and there is nothing peculiar in the circumstance that 
in acute hydrocephalus they are sometimes found dark red, and then 
again very pale and aneemic. If it is desired to institute a chemical 
examination of the hydrocephalic fluid, which is very instructive, 
the ventricle should be punctured very cautiously with a trocar and 
only the fluid thus evacuated should be examined ; for, if the whole 
quantity of liquid that escapes on opening the ventricle be collected, 
it will always be found to be a mixture of blood and cerebral dropsi- 



DISEASES OF THE NERVOUS SYSTEM. 34I 

cal effusion, wliicli is entirely unfit for the purpose of such a chemical 
examination. 

Tlie chemical analysis of a pure hydrocephalic effusion furnishes 
extremely peculiar results, to which C Schmidt first directed the 
attention of the profession. The chemical reaction of this fluid is 
always distinctly alkaline ; it is almost as clear as water, and contains 
only traces of albumen, for, on boiling it and testing it with acid, it 
is rendered hardly perceptibly turbid, and precipitates no large dense 
flakes of albumen. The proportion of salts in the effusion is also a 
peculiarity that deserves to be mentioned. While the transudation 
collected from the peripheral meninges, pia mater, and arachnoid, 
contains the salts exactly in the same proportions as the exhalations 
from other serous membranes — to wit, in the proportions of the serum 
of the blood — the transudation of the choroid plexus contains more com- 
binations of potassium and of phosphorus, so that the proportion of 
potassa to soda and that of the phosphates to the chlorides, approxi- 
mates nearer the salts as they occur in the blood-corpuscles. While 
the salts of the meningeal transudation, according to G, Schmidt^ 
contain 2.8 per cent, of potassa and 40 per cent, of soda, in the salts of 
the fluid from hydrocephalus internus nearly 17.8 per cent, of potassa 
and only 27.2 per cent, of soda are found. We have therefore in this 
case no mere filtration of the serum of the blood, but a peculiar secre- 
tion, in the formation of which the salts of the corpuscles of the blood 
seem to participate. 

The walls of the ventricles are more or less softened, and their 
ependyma (lining membrane) is destroyed. The distention of the 
lateral ventricles is often of such an extent as to rupture the septum 
ventriculorum, and the two cavities then directly communicate with 
each other. In extreme cases this softening is also found in the optic 
thalami, in the 'corpus callosum, and in the corpus striatum, the upper 
surface of which appears eroded, shreddy, flocculent, and uneven. The 
choroid plexus is bloodless, very pale, and not superabundantly filled 
wdth blood, as is unaccountably stated in most of the late French 
works. This bloodlessness is very natural, for the enormously accu- 
mulated fluid must very greatly impede the filling of this arterial 
plexus. The anaemia, in connection with the general dilatation of the 
ventricles, is the best criterion by which to judge of the extent of the 
hydrocephalus, if accidentally or incautiously the liquid, on opening 
the skull, has been allowed to escape prematurely. 

This part of the examination having been concluded, we then turn 
our attention to the base of the brain. Here a whitish or ffreenish- 
yellow exudation of a peculiar gelatinous nature is seen to have been 
deposited in and between the pia mater and the arachnoid membrane. 



342 DISEASES OF CHILDREN. 

By tliis exudation tlie sulci of the brain have become agglutinated 
and plastered over, and the depressions at the base of the brain, espe- 
cially those corresponding to the cella turcica, are evenly filled out 
and obliterated. The exudation is most abundantly accumulated 
within the bilateral hilus cerebri, from the chiasma opticum to the 
pons, over this on to the medulla oblongata, and spreads upward, 
especially into the fossa Sylvii, and the longitudinal fissure of the 
cerebrum. Here, in the fossa Syh^ii, along the artery and vein, the 
tuberculous character of this exudation is most distinctly recognized, 
for here, in particular, a countless number of fine white granules is 
seen, which, on microscopic examination, prove to be mihary tuber- 
cles. They consist entirely of an amorphous granular mass of detri- 
tus ; the fibres of connective tissue seen here and there do not belong 
to the miliary tubercles, but to the pia mater, in which the tubercles 
are embedded. Miliary tubercles, in addition to being found in the 
fossa Sylvii, are also seen to have been deposited over nearly the en- 
tire base of the brain, especially along the course of the vessels. 

In regard to the other organs, it is always observed in this afifec- 
tion that an older, larger, yellow tubercle exists somewhere in the 
body, most frequently, in fact, in the bronchial glands ; next in the 
lungs, then in the brain itself, and sometimes also in a bone. The 
connection between acute hydrocephalus and softening of the stomach, 
mentioned in some text-books, in reality does not exist, as has already 
been clearly shown in our remarks on softening of the stomach, page 
149. 

Symptoms. — The disease most frequently attacks children from 
two to seven years of age. The youngest child in whom meningeal 
tuberculosis has been observed was three months old ; in older chil- 
dren and adults the miliary tuberculosis localizes itself much oftenei 
in the lungs than in the meninges. 

Many di^dsions into stages have been proposed with a view of 
facilitating the study of this disease. Thus (1) a stage of conges- 
tion ; (2) of inflammation ; and (3) of exudation, have been assumed. 
JSoiichut speaks of a stadium prodromorum, invasionis, and convul- 
sionis, but, strictly speaking, no stadial division, based upon patho- 
logical anatomy, can be assumed ; symptomatically, one into (1) a 
stage of irritation and (2) of paralysis may be practicable. In the 
first stage, the prodromata and the symptoms of hydrocephalus that 
have already appeared may be recognized. 

The prodromata are of an extremely peculiar and variable form. 
Although it certainly cannot be denied that the study of these has been 
extended somewhat too far, and that much that is irrelevant has been 
added to them, still their existence cannot be ignored. Above all, 



DISEASES OF THE NERVOUS SYSTEM. 34.3 

it is necessary to determine whether the acute hydrocephalus has de- 
veloped itself in a child, who, for a long time previously, has had dis- 
tinct signs of tuberculosis — usually pulmonary — or whether these 
signs have hitherto been absent, and the disease has developed itself 
in an apparently perfectly healthy child. It is, indeed, asserted by 
some hospital physicians that the premonitory signs may be totally 
absent, and the symptoms of developed inflammatory hydrocephalus 
may come on at once ; in private practice, however, such cases have 
not been observed. Here, for several days, sometimes even for many 
weeks, some tolerably constant prodromata are always noticed, which 
only slowly become aggravated, till we finally have the disease before 
us developed in its most dangerous form. 

This stadium prodromorum usually lasts two or three weeks, 
though cases are also met with where the children present these signs 
for several months. The most constant of these symptoms is a slow- 
ly progressive emaciation, which, in a most remarkable manner, en- 
tirely spares the face, so that the child, when dressed, presents noth- 
ing unusual in its appearance. But observing mothers and nurses 
invariably notice it, and the prominence of the ribs, in particular, ex- 
cites their apprehension. A slight pallor of the countenance, and a 
peculiar lustre of the eyes, soon become associated with this condition. 
The patient now loses all healthy cheerfulness and liveliness habitual 
to it. It sleeps more than usual, soon forsakes its amusements, be- 
comes morose and timid before others, and cries for the slightest cause. 
It is also very remarkable that it does not attempt any of its former 
httle braveries, for instance, the climbing upon chairs, the opening 
of difficult door-latches. Even the looking out of a grated window 
intimidates it, and, when requested to perform these feats, it will 
sternly refuse. Boys who formerly would put up with nothing from 
their comrades, but were always ready to fight and defend themselves, 
now cowardly slink away crying. Other children, again, become re- 
markably affectionate, constantly embracing and clinging to their 
parents, and, when left alone, are inconsolable. 

In older children, who have already commenced study, the tutor 
notices an unusual absent-mindedness and indifference ; the learning 
by heart is more difficult than before, and what is finally acquired is 
uttered in a stuttering manner. The children sleep very much, and 
often fall asleep in the daytime. Their night-sleep, however, is 
not sound, is repeatedly broken by unpleasant dreams; they toss 
about in bed, and frequently break out into apprehensive exclama- 
tions. The appetite is gone ; often there are capricious longings for 
stimulating food, of which, however, but little is consumed. The 
thirst is not augmented, the secretion of urine but slightly diminished ; 



3J:4 DISEASES OF CHILDREN. 

the urine is often so rich in urates that they settle on the bottom of 
the vessel, and form what has been called the brick-dust sediment. 
The bowels are usually torpid, particularly in older children ; but, 
should a diarrhoea exist, it should not, by any means, be interpreted 
as incompatible with the existence of acute hydrocephalus. Particu- 
larly in infants, who are still laboring under the first dentition, it often 
haj^pens that the ordinary diarrhoea of dentition continues as in the 
normal state, and an acute hydrocephalus has nevertheless been in- 
trenching itself. Headache is scarcely ever complained of, even by 
older childi^en ; vertigo and an unsteadiness on walking are much oftener 
observed. Some time ago, a boy four years old, who displayed sev- 
eral premonitory symptoms of acute hydrocephalus, was brought to 
me. On walking upon the even floor, he always, lifted up his feet 
very high, as if mounting a stej^. In the course of a few days the 
disease developed itself more markedly, and the autopsy subsequently 
confirmed the diagnosis. These children tolerably often complain of 
abdominal pains, which are distinctly aggravated on pressure. Fever 
is usually not present ; still, what has been said of diarrhoea is also 
applicable to tliis symptom, the presence of fever is no reason what- 
ever for excluding the possibility of a commencing hydrocephalus. 

The S}Tnptoms just described, conjointly or singly, now become 
more and more aggravated ; the children betake themselves to bed, 
and hereupon the signs of commencing effusion, likewise those of 
cerebral irritation, develop themselves. 

Different are the circumstances when children with marked pul- 
monary tuberculosis in addition acquire meningeal tuberculosis and 
hydrocephalus. In this case, the symptoms of the jDreexisting phthisis 
pulmonalis, such as hectic fever, excessive weakness, severe bronchitis, 
etc., are naturally so conspicuous that the prodromata, dehneated 
above, are scarcely noticeable. Then, the disease begins directly \Adth 
the symptoms of commencing effusion, and the irritation produced by 
that process. 

The most characteristic symptoms of the stage of irritation are : 
vomiting, constipation, slow pulse, unrhythmical respiration, increased 
temperature of the skin, retracted abdomen, headache, extreme ex- 
citability alternating with somnolence, diminution of the intelligence, 
and the various kinds of motor disturbances. 

The jDreponderating symptoms of the stage of paralysis are : great 
acceleration of the pulse, profound coma, and paralysis of the volun- 
tary muscles. In order not to break off constantly in the description 
of the individual symptoms, and as the transition of one stage into the 
other can b}^ no means be so accurately defined, as some of the text- 
books declare, this stadial division will, therefore, be dispensed with 



DISEASES OF THE NERVOUS SYSTEM. 34,5 

in the following delineation, and eacli symptom will be followed at 
once to its fatal end. 

As regards the disturbances of the digestion, vomiting must rank 
first. It is a remarkably constant symptom, and usually comes on so early 
in the disease that the diagnosis may be established by it much earlier, 
and with greater precision than by any other symptom. The duration 
of the vomiting, however, is very variable. Some children vomit for 
only one day, others several days, and only a part of the food partaken 
of. Others, on the contrary, vomit incessantly from the commence- 
ment of the disease almost till death, and there is no article of food 
which is not vomited almost as soon as it is taken. A peculiar feature 
about this vomiting is, that it makes no remission, never recurring, 
after it has once ceased for twenty-four hours. The manner in which 
the children vomit is of the utmost importance in the formation of the 
diagnosis. While children who suffer from an indigestion are afflicted, 
for a long time before the actual vomiting, with nausea, eructations, 
retchings, and cold sweats, hydrocephalic children vomit without any 
such preparations, just as if they had taken a mouthful of water and' 
then simply spat it out again. The act of vomiting is facilitated by 
setting the children upright, or by laying them on the side. It is 
arrested so long as the stomach remains entirely empty ; when liquids, 
and, still more so, compact nutriments are introduced, they are in- 
stantly ejected without any apparent distress or difficulty. Yery sel- 
dom is the matter vomited mixed with bile, a circumstance that is 
readily explained by the slight antiperistaltic action of the stomach. 
As the physician seldom personally witnesses the act of vomiting, 
and, consequently, has to rely entirely upon a verbal description of it, 
he should accurately question the relatives, and make them understand 
that they are carefully and minutely to observe the manner of vomit- 
ing — whether it is easy or difficult, with or without retching. 

A second almost equally as constant a symptom is constipation^ 
from which at least three-fourths of all the hydrocephalic children 
suffer. The intestinal secretions are so diminished that even the more 
powerful drastic cathartics have no effect, even when they are not 
vomited, which very often occurs. Calomel, so much in vogue in 
other forms of constipation in children, is almost entirely inert in this 
one. This constipation does not continue till death; latterly, thin 
colliquative stools are voided, no matter whether aperients have been 
employed or not. Even profuse diarrhoeas, the effects of intestinal 
tuberculosis, may cease in commencing h3^drocephalus, but the stools 
which subsequently follow are again thin, and have the well-known 
putrid odor. As a rule, constipation is less constantly observed than 
vomiting, for instances not very infrequently occur in which regular 



346 DISEASES OF CHILDREN. 

stools take place daily from the invasion till the end of the disease. The 
material diminution of their quantity is very natural, and is to be ex- 
plained by the diminished consumption of nutriments. The appetite 
is gone, and the food that is laboriously administered is vomited, and 
it is, therefore, very easy to comprehend how a constipation of several 
days' duration may occur, and in which the abdomen nevertheless be- 
comes more and more retracted, and no fecal matter passes through 
the intestinal canal. 

The rest of the alterations of the digestive apparatus are less 
pathognomonic. The thirst never becomes so intense as in other 
acute febrile conditions, for example, typhus fever, or the acute exan- 
themata, and the secretion of urine is correspondingly always very much 
diminished. This absence of thirst is, in fact, a natural result of the 
slightly-increased temperature of the skin, and the inconsiderable 
acceleration of the pulse, and of the disturbed innervation of the 
stomach. The urine is very concentrated, rich in urates, uric acid, 
coloring matter, and salts, and therefore deposits in the bladder, or 
immediately after it is voided, a thick sediment. Toward the end of 
the disease, the child often passes no water for twenty-four hours, 
or even more, and yet the bladder does not become distended, show- 
ing the existence of a paralysis of the nerves governing this secretion. 
The urine that is finally discharged, or drawn ofi" by the catheter, is 
turbid, has a pungent odor, and an ammoniacal reaction. Albumen, 
so far as I am aware, is not found in it. 

The appetite is seldom as completely absent as in the diseases just 
alluded to ; though it is true that there is no desire for food, still it is 
almost always possible, without any great difficulty, to administer 
milk or beef-broth to such patients, and this is all the more surprising, 
as vomiting almost invariably follows. 

In this stadium, the tongue is always moist, more or less coated 
with a white fur, and furnishes nothing characteristic. The tongue 
remains moist in almost all infantile diseases, which is due to the cir- 
cumstances that the mucous secretion of the mouth is very profuse at 
this age, and that children have the good habit of sleeping with the 
mouth shut. The gums are likewise always moist, but on these, too, 
the white fur that appears in most of the diseases is also seen. 

The febrile phenomena in hydrocephalus are never of high grade. 
In miliary tuberculosis, which develops itself entirely in the pia mater, 
fever can hardly be said to ever occur ; but if, on the contrary, the 
miliary tuberculosis involves other organs also, especially the lungs, 
or the peritonaeum and pericardium, as pungent a heat of the skin ap- 
pears as is commonly met with at the eruption of an acute exanthema. 
The temperature of the head, particularly the forehead, is, in all in- 



DISEASES OF THE NERVOUS SYSTEM. 347 

stances, decidedly elevated, and remains so to the end, while the feet 
are very prone to become cold. 

In general, the temperature of the skin stands in exact relation to 
the rapidity of the pulse, but the forehead always remains hot, even 
when the pulse becomes ever so slow. 

The condition of the pulse has always been regarded as of 
great importance in acute hydrocephalus, and there is, in fact, no 
disease in which it deserves so much attention as in the one under 
consideration. In the incipiency of the malady, the frequency of the 
pulse is due more to the miliary tuberculosis that has developed itself 
in the other organs than to that of the meninges. When the miliary 
tuberculosis is very extensive, and in course of development in the 
rest of the organs, the consequent acceleration of the pulse will coun- 
teract the retardation actually caused by the cerebral affection, and 
may continue for many days, till finally the slow hydrocephalic pulse 
comes on. If, on the contrary, the meningeal tuberculosis occurs, 
the retarded pulse soon manifests itself, and is readily recognized by 
the lessened frequency and modified quality of its beats. Whatever 
may be the explanation, it is a fact that the pulse, at the commence- 
ment of acute hydrocephalus, is often accelerated, but that in other 
cases it also becomes slower and slower from the first day of the dis- 
ease on. In the majority of cases, it is at first shghtly accelerated, 
and becomes retarded in a few days. As the watery effusion in the 
cerebral cavities becomes augmented, the number of the beats sinks 
down to between forty and sixty ; usually, however, the pulse does 
not remain stationary upon any definite number, but changes from 
hour to hoiu", so that, in the course of twenty-four hours, it may be 
forty, then sixty, and then, again, eighty per minute. These varying 
conditions of the pulse are differently explained by different clinical 
observers. Whatever view they take, I have often convinced myself 
of the correctness of the fact. In most cases qualitative changes 
of the pulse also occur, a strong throb follows several small ones, 
or vice versa ; also distinct but not regularly-recurring intermissions 
take place, and sometimes the pulse assumes a peculiar vibrating 
character, imparting to the finger a sensation as if it rested upon a 
vibrating string. This character disappears as soon as the finger 
presses a little more firmly upon the artery, and an easy, cautious 
touch is, therefore, necessary for this examination. 

One to three days before death, the pulse again becomes rapid, 
and indeed so rapid that it is hardly possible to count it. It may 
reach 180 to 200 in the minute. When this continually-augmenting 
frequency of the pulse supervenes upon the above-described retarda- 
tion, with its accompanying alteration of quality, a speedy end may 



348 DISEASES OF CHILDREN. 

be prognosticated with the utmost certainty, for this great accelera- 
tion is to be interpreted as indicating commencing paralysis of the 
pneumogastric nerve. 

The alterations of the respiration are also of great importance. 
At the invasion of the disease, the breathing goes on normally, except 
in those cases where the miliary tuberculosis in the lungs has made 
great progress, and the fever is intense. Then, of course, the 
respiration is very much accelerated, and this acceleration is due as 
much to the local disturbances as to the fever, with its implication 
and depression of the organism. But as soon as the symptoms of 
exudation have become more prominent, then they are also infallibly 
manifest by the respiration. It, for example, becomes much slower 
and completely unrhythmical. In one minute the child respires fifteen 
times, in the next thirty, and in another twenty. At one time the 
respirations are superficial, and occur with a barely perceptible dilata- 
tion of the thorax, and without any audible sound ; then, again, they 
are deep and sighing. This latter kind of respiration is so constantly 
observed, that these have been called hydrocephalic sighs. This re- 
tarded and unrhythmical respiration takes place in all cases, even in 
those where advanced pulmonary tuberculosis gives rise to marked 
acceleration of the acts of respiration. Occasionally the breathing is 
arrested for ten seconds and more ; and the next gasp, that is waited 
for by the parents with anxiety, occurs as a deep, long sigh ; and, im- 
mediately upon that, several very normal, tranquil inspirations follow. 
If the pulse, shortly before death, has assumed that extraordinary 
rapidity already described, the respiration also will become more rapid 
again — about as rapid, but not as rhythmical, as in the normal con- 
dition, and by no means in exact proportion to the extreme frequency 
of the pulse. 

The physical examination of the lungs furnishes either entirely 
negative results, or in some cases it reveals the presence of pulmonary 
tuberculosis with cavities, which, in childhood, very remarkably, are 
much more often met -u^th in the lower lobes than at the apices of 
the lungs. For a long time I have been in the habit of repeatedly 
and attentively percussing the sternum in all hydrocephalic children, 
on the supposition that the ordinary bronchial glands, swollen into 
large masses, would produce an especial dulness in that region. This 
examination, however, has proved to be entirely fruitless, for the 
bronchial glands, even when they are ever so much enlarged, are never 
enlarged anteriorly toward the sternum, but always laterally into the 
luno's, downward beneath the bifurcation of the trachea, and backward 
toward the spinal column. Hence the reason why no extensive dul- 
ness is ever observed over the sternum, although, at the autojDsy, the 



DISEASES OF THE NERVOUS SYSTEM. 349 

tuberculous broncliial glands are found hypertropliied to the size of a 
pigeon's and even to that of a hen's egg. 

The phenomena presented by the skin are of inferior importance. 
At the commencement of the disease the skin is commonly moist ; 
active sweating of the head is also observed ; but, as the disease ad- 
vances, the skin becomes dry, brittle, and furfuraceous, and no sweating 
takes place again until the fatal accelerations of the pulse come on, 
near the close of life. Sudamina are comparatively rare. The integu- 
ment retains its susceptibility to counter-irritants up to the fatal 
end; the horrid anointings with ung. tartar, stibiat. or of sublimat., as 
well as the vesicators, act as promptly in hydrocephalic as in heakhy 
children. So, too, the simple rubbing in of blue ointment, in children 
with a tender epidermis, produces the ordinary vesicular eruption. 

In the French compendiums there is a description of peculiar 
meningitic spots {taches mbmigitiques) ; it is asserted that they 
originate when the integument over the chest and abdomen is 
scraped and much irritated with the finger-nail, and that they leave 
behind them scarlet-red streaks, w^hich, in a few minutes, indistinctly 
merge into the surrounding rose-colored skin. I have often tried to 
produce these " meningitic spots," but have never been able to detect 
any thing more than a red streak, the same kind, in fact, as may be 
produced almost instantaneously by simply scratching any free part 
of the skin in a healthy individual. 

These " meningitic spots " were discovered by Trousseaic^ who has 
enriched the Psediatrica with many similar " discoveries." That red 
spots should originate on the skin, in consequence of local congestion, 
sometimes at one place and then again at another, but especially on 
the face, is a phenomenon that by no means belongs particularly to 
hydrocephalus. Their frequent occurrence here finds a very natural 
explanation in the unrhythmical pulse, and in the attending disturb- 
ances of the circulation. 

Headache, likewise, is a prominent and tolerably constant symp- 
tom ; but it does not come on so early as might be supposed, w^ere we 
to judge from the primitive cause of the entire disease, which, in real- 
ity, is to be looked for in the meninges. Indeed, it is almost uniformly 
absent in the premonitory stage, as has already been stated. It comes 
on with, or a short time previous to, the vomiting, and soon becomes 
so severe that older children constantly cry aloud from pain. Younger 
ones pluck at the head and ears with their little hands, and restlessly 
toss the head about or rub it to and fro on the pillow. These mani- 
festations of pain continue as long as the children are in possession of 
their faculties. Usually, no defined place on the skull is complained 
of; still, when asked concerning it, they will point, in the majority of 



350 DISEASES OF CHILDREN. 

cases, to the forehead. In younger children automatic movements 
occur, which also seem to be referable to the headache, and mostly 
consist in carrying one or the other little hand to and from the head 
with great rapidity. Generally, the pains do not intermit, but continue 
unceasingly till coma finally supervenes. 

Older children remarkably often, still not regularly, complain of 
abdominal pains^ especially in the epigastric region. These pains 
are materially aggravated on pressure, and may become so intense, 
whenever the stomach or any part of the abdomen is touched, that the 
patients utter loud, painful outcries. They do not, generally, per- 
sist as long as the headache, but they are apt to cease suddenly and 
to return. It is not always possible to attribute them to any patho- 
logical alterations of the intestinal mucous membrane. I have care- 
fully examined the stomach and intestines in numerous autopsies of 
hydrocephalic children, in whom the abdominal pains were extremely 
well pronounced, but have never been able to discover any marked 
morbid changes. 

The shape of the abdomen is extremely pathognomonic of the dis- 
ease. At first nothing in particular can be observed ; but, when vomit- 
ing, constipation, and the general hydrocephalic symptoms, have lasted 
for some time, the abdomen will daily become smaller, plaited, and de- 
pressed, and finally acquire the form of a boat. By very shght press- 
ure, the abdominal aorta can be distinctly felt on the spinal column. 
This boat-shaped belly is generally explained by a paralysis of the 
abdominal muscles, which are said to simply overlie the contracted 
alimentary canal. This condition, however, is by no means produced 
by a paralysis, but by a permanent spasmodic contraction of the 
transversalis and obHque abdominal muscles, in which the muscular 
coat of the intestines also probably participates, for the intestinal tube 
is always found remarkably contracted. A certain degree of hardness 
and tension always remains in the abdominal parietes, even when this 
trough-like formation of the belly is extreme. On the other hand, a 
paralysis sometimes ensues in the last days of life, when the rigid de- 
pression of the abdomen disappears and the retracted abdominal walls 
become again soft and flabby. The case is difi'erent with the integu- 
ment covering the abdominal walls. Paralysis afi'ects it very early 
in the disease, as may be seen when a fold, having been raised by 
pinching with the thumb and forefinger, takes a long time to dis- 
appear. 

The retraction of the abdomen is not absent in any case of hydro- 
cephalus, and the description, hoat-shaped^ is very appropriate, for 
the symphysis pubis, the costal cartilages, and the ensiform cartilage, 
form high jDromontories, between which the contracted abdominal 



DISEASES OF THE NERYOUS SYSTEM. 351 

muscles represent a deep trough. Goelis regarded this symptom as 
of especial importance, and believed that by it acute hydrocephalus 
could be distinguished from typhus fever with the greatest certainty. 

As regards the external alterations about the skull, they can only 
be observed in cases of unclosed fontanels. These will bulge out 
more and more with the augmentation of the effusion, and exhibit 
distinct fluctuation. In cases where the fontanels are already closed, 
a peripheral circulation of the veins of the scalp sometimes becomes 
rapidly developed, the result of pressure by the effused fluid upon the 
sinuses of the dura mater. 

"Yi^Q psychical functions experience disturbances very early in the 
disease, in a manner that has already been described more minutely 
in the stadium prodromorum. The confused, blank look, the morose, 
peevish, irritable disposition, or, in other cases, the utter indifference 
toward beloved persons and objects, are the most striking peculiari- 
ties. Later, when the rest of the symptoms have already placed the 
diagnosis beyond all doubt, actual delirium also supervenes, but gen- 
erally of a quieter kind than in purulent meningitis of the convex 
portions of the cerebral membranes. Furious delirium in the course 
of acute hydrocephalus occurs only exceptionally, and for very short 
periods, and is soon followed by quiet, muttering delirium, and 
this by a permanent state of profound coma. The intensity of the 
dehrium, and the nervous symptoms in general, according to the 
investigations of Milliet and Bcirthez^ and which I have often been 
able to confirm by dissections, are by no means in exact relation to 
the extent of the disease found in the meninges. In cases of violent 
cerebral symptoms, where a thick layer of exudation and a large 
quantity of miliary tubercles were predicted, traces of them only were 
found here and there at the autopsy ; and, in cases where no delirium 
at all, and only coma, was present in the last period of life, large 
quantities of effusion and extensive miliary tuberculosis have often 
been observed. 

A very common symptom is a loud, mournful cry, recurring at 
longer intervals, and which Coindet considers so pathognomonic of 
this disease, that he unhesitatingly describes it as the " hydrocephalic 
cry." These children also often repeat for whole nights, at regular 
intervals, some monosyllables in a plaintive voice, or repeatedly ex- 
claim, " O my ! " which is always accompanied by a loud, deep sigh. 
These symptoms of irritation, extremely distressing and annoying to 
the sympathizing relatives to witness, fortunately do not last, at the 
utmost, longer than six or eight days, and are followed by profound 
stupor. 

When these children have once fallen into a state of coma, they 



352 DISEASES OF CHILDREN. 

never, as a rule, come out of it ; sometimes, however, coma and de- 
lirium alternate, but the former always is predominant. JRilliet and 
JBartJiez report the cases as very rare in w^iich perfect consciousness 
returned, only to be quickly succeeded by the previous coma. 

The disturbances of the locomotive apparatus are extremely vari- 
able, and are not completely absent in any case of hydrocephalus, but 
they generally come on so late in the disease, that they can take but 
little share in the formation of the diagnosis. The stadium in which 
they appear is of great interest to the neuropathologist, and supphes 
some explanation of the innervation of different parts of the body. 
Convulsions and paralysis occur, the former preceding the latter, and 
it is necessary for us to distinguish between the general and local 
convulsions. 

The general convulsions occur paroxysmally. At first the inter- 
vals between the paroxysms are long, three or four days frequently 
passing between the attacks. Generally, however, they recur oftener, 
and in some rare cases may last for many hours continuously. Usually, 
they begin at the inspiratory muscles, producing a suspension of the 
respiration, which is interrupted a few times in the minute by a rapid, 
incomplete act of breathing. They soon extend to the extremities, 
which are vehemently shaken by rapidly-recurring electro-tetanic jerks, 
which alternate with strong supinations of the forearms, and with 
opisthotonos. This very naturally induces marked venous stagna- 
tion ; the face becomes red and even livid ; the eyes injected, roll 
about in different directions, but mostly stare upward to such a degree 
that the pupil and but little of the iris are seen between the half-closed 
lids. After several minutes, sometimes after two or three hours, these 
general convulsions cease, when the patients, pale as death, sink into 
a state of the utmost prostration, and exhibit a marked aggravation 
of the general condition. 

The local convulsions attack the most varying groups of muscles, 
most frequently those of the face. Here distortions of the upper lip^ 
a spasmodic smile^ and peculiar sucJcing acts, occur, by which the lips 
are kept in motion for hours. Strabismus is observed late in the dis- 
ease ; sometimes the child squints outward, and then again inwai;<i. 
The strabismus is often not permanent, but is subject to the partial 
irritation, or antagonistic paralysis of the various muscles of the eye- 
ball, and in the last days of life it may disappear entirely. 

This symptom, as has been said, comes on late; still, I can recall 
the case of a child which was brought to me simply on account of 
the daily increase of squinting. In the succeeding da^'-s other hydro- 
cephalic symptoms steadily developed themselves, and at the autopsy 
a tubercle as big as a hazel-nut was found in one of the optic thalami. 



DISEASES OF THE NERVOUS SYSTEM. 353 

Another peculiar symptom is the gnashing of the teeth, well known 
to and justly dreaded by experienced nurses. It also is due to a 
spastic contraction of the masticators, and is protracted till complete 
general paralysis takes place. Active partially automatic movements 
of the arms take place, and are described as twitchings, tremors, or 
startings of some of the tendons, while many hydrocephalic patients 
constantly keep their hands about the genitals and perform onanistic 
acts. 

The lower extremities are less frequently attacked by convul- 
sions than the upper; they are almost always in a semi-flexed 
and paralji;ic state; when spasms appear, they will be of the 
character of short tetanic jerks, during which the toes are mdely 
separated. 

The muscles of the na2^e and hacJc are strongly contracted, and 
most of the subjects, when set upright or laid on the side, throw the 
head far backward. The tonic spasm of the abdominal muscles, by 
which the well-known boat-shaj^ed belly is produced, has been already 
mentioned. 

The disturbances of the sensibility, and the derangements that take 
place in the organs of sense, are no less remarkable. In most of the 
patients a decidedly heightened sensibility of the skin is observed at 
the invasion of the disease, which manifests itself by a greater sus- 
ceptibility to external impressions. When raised from the bed ever 
so tenderly, or their posture changed however carefully, or the head, 
abdomen, or hands, touched ever so lightly, they will always resist 
and utter loud cries of pain. But this morbid picture changes rapidly 
as the effusion continues to increase, for paralysis of the nerves of 
sensation quickly ensues, and the child may be pricked, pinched, 
or handled, mthout any special care, may be treated with vesi- 
cants and irritating ointments, yet will make no opposition, merely 
manifesting by a low moan any pain it may suffer. The abolition of 
the sensibility is very strikingly shown in the conjunctiva, which may 
be stroked with the finger without causing the lids to move. 

In addition to the strabismus, which has already been described in 
connection with the motor disturbances, and besides the blank, sur- 
prised look of the eyes, the state of the inipils, and the augmentation 
of the mucous secretion of the lids, are also worthy of notice. The 
pupillary contraction is very transient and by no means constant ; gen- 
erally the pupil has a tendency to dilate very early in the disease, and 
this dilatation perceptibly increases from day to day. ToAvard the 
end of the disease, the remarkable phenomenon of inequality of the 
pupils supervenes. Thus, in a child three years old, I noticed in its 
last days of life a unilateral dilatation upon the side on which it 
23 



354 DISEASES or childken. 

happened to lie, and at the same time a peculiar oscillatory move- 
ment of tlie same eyeball, while the pupil and globe of the opposite 
eye remained undisturbed. By laying the child on its other side, I 
succeeded several times, though not always, in producing these altera- 
tions in the eyeball which previously had remained tranquil, while 
the other ceased to oscillate. 

The observation of JBrachet, that, under the influence of a strong 
light, the pupils which are already dilated will contract for a short 
time, and in one or two minutes dilate again, notwithstanding the 
continuance of a still more intense light, I have often been able to 
confirm. But, in the last days of life, even the most glaring Hght 
fails to make an impression upon the pupils. The secretion of the 
conjunctiva and Meibomian follicles increases during the disease, and 
it becomes necessary several times a day to remove the accumulated 
masses of mucus which collect at the inner angles of the eyes. 

The hearing seems to continue longer, for the children, until they 
are completely comatose, will rouse somewhat upon being called 
by name, and even when spoken to in a low voice. The taste and 
smell become abolished only toward the fatal end ; for the child very 
decidedly objects to being rubbed with ointments of bad odor, and 
refuses to take unpleasant-tasting remedies. 

As regards paralysis, it may be remarked that general, lasting pa- 
ralysis, such, for instance, as occurs after a commotio cerebri^ is never 
observed. Hemiplegia, on the other hand, occurs in some cases, and 
lasts till death. At the autopsy, in addition to the miliary tubercu- 
losis of the meninges, one or several large, old, yellow tubercles are 
generally found mthin the brain. Most frequently paralysis of one or 
the other upper eyelid, or one half of the face, with participation of 
the muscles of the tongue, is observed. Paralysis of one of the 
upper extremities, and more rarely of one of the lower "extremities, also 
occurs. The retention of urine in the last days of life is, as has al- 
ready been stated, not to be attributed so much to a paralysis of the 
bladder as to a paralysis of the secretory nerves, for usually the blad- 
der does not become distended so as to be felt above the symphysis 
pubis, and the catheter discovers no large quantities of urine. 

Death, as a rule, ensues after violent convulsions of many hours' 
duration, and only exceptionally do the paralytic symptoms steadily 
advance to a fatal termination. 

In the majority of cases it is very easy to make out an approxi- 
mative diagnosis, but whether it is of a tuberculous, or simply of a 
purulent inflammatory nature, it is usually imjDossible to decide. In 
both processes, the cerebral symptoms are alike, only in the simple 
meningitis they come on much more rapidly and are more violent, ter- 



DISEASES OF THE NERVOUS SYSTEM. 355 

minate more quickl}-, and possibly may also end in recovery, while tu- 
berculous meningitis must be put down as an inevitably fatal disease. 
More concerning this may be found in the section which treats of 
simple meningitis. With tj'phus fever it is scarcely possible to con- 
found this disease, if any diagnostic skill at all be exercised. The 
diarrhoea, the tympanitis, the rapid pulse, and the splenic tumor, are 
such constant signs of typhus fever, ivhile the retracted abdomen, the 
constipation, the manner of vomiting, the slow pulse, and the unrhyth- 
mical breathing, are such striking symptoms of hydrocephalus, that 
an error in the diagnosis can hardly happen. It is more probable 
that a chronic gastric catarrh, from which older children become ema- 
ciated, and with which some cerebral symptoms may also be asso- 
ciated, may mislead us, and cause the two diseases to be confounded. 
In the section on intestinal worms a case was related, where a child 
perished under hydrocephalic symptoms, and at the autopsy nothing 
but a large c^uantity of round-worms was discovered. 

Although these cases must be regarded as extraordinary rarities, 
still we have seen that some verminous patients have wide pupils, that 
they vomit frequently, and even have slow pulse, and consequently 
we may easily be misled to entertain the supposition that we have an 
incipient though irregular hydrocephalus to treat. 

A^Tiat has been said hitherto has only reference to the completely- 
developed affection, not to the prodromata, which by no means admit 
of any diagnostic precision. This stage is, indeed, frequently con- 
founded with commencing typhus fever, or with simple gastric catarrh, 
with helminthia and irregular and difficult dentition, and to these 
errors no doubt are also due the many reported cases of cured menin- 
geal tuberculosis with hydrocephalic effusion. But the most essen- 
tial points will always be found in the hereditary disposition, by the 
aid of which, in the doubtful cases, we are able to establish the diag- 
nosis w^ith tolerable certainty. If the father or mother, or one of the 
brothers or sisters, have already perished by tuberculosis, the prob- 
ability that the doubtful symptoms belong to acute hydrocephalus 
becomes much greater than when no tuberculosis at all can be de- 
tected in the history of the family. 

Termination and Prognosis. — I recollect to have had, at the very 
commencement of my professional career, a tolerably well-pronounced 
case of hydrocephalus, in which the child, after several weeks, was 
apparently perfectly cured. But the same boy, seven or eight years old, 
one year after his first sickness, again came under treatment, and then 
succumbed to- a meningeal tuberculosis and extensive hydrocephalic 
effusion, which was demonstrated by the j^ost-mortem examina- 
tion. 



356 DISEASES OF CHILDREN. 

In all the rest of my hydrocephalic patients, of which I have had 
at least thirty, death, when the s}Tnptoms once indicated cerebral 
dropsy, invariably ensued after two to three weeks. But, by thus de- 
fining the time, we do not intend to say that the disease will always 
run its course within such a period ; for in no disease is it so difficult 
to determine the time of commencement as in the one under considera- 
tion. Formerly it was customary to date the commencement of the 
disease from the day on which the child took to the bed, but attentive 
mothers observe a whole list of symptoms for weeks and even months 
before this, which they are unable to explain, and for which they con- 
sult the physician. 

As in my own experience not a single child has recovered from 
this disease, and only a single one has overcome one attack to perish 
from a relapse during the foUo^^ing year, I am forced to regard the 
prognosis as absolutely fatal. On the other hand, humanity, as well 
as policy, commands us to afford the relatives a ray of hope till the 
fatal end, for, by inspiring hope, the labor of nursing is vastly light- 
ened, and you retain the patient, and thus keep it out of the hands 
of others who may manage it less humanely. 

Cases are recorded which purport to be recoveries from acute 
hydrocephalus, and their truthfulness is vouched for by names of good 
repute. It is, however, hardly necessary for me to state that I have 
tried the treatment recommended in these cases with the utmost care 
and accuracy, and have, nevertheless, always experienced the same 
uniformly unfortunate result. 

Treatment. — The only essential service which the physician is able 
to render in this terrible disease is to be sought for in establishing a 
strict prophylaxis in these tuberculous famihes. Every thing that is 
Hable to produce cerebral congestion must be strictly prohibited. 
Such children must not be mentally overtaxed, nor allowed to exert 
their faculties for any length of time continuously. They should not 
play at wild, boisterous games, should not run long nor rapidly, nor 
jump, nor dance, etc. Their heads should always be cool, and be well 
protected against the direct rays of the sun. In general, all those 
precautionary measures to be hereafter recommended, in tuberculosis 
as a dyscrasia, are to be scrupulously observed. Especial attention is 
to be bestowed upon the state of the bowels, for constipation is well 
known to be a frequent and an active cause of cerebral congestion. 
The stools, however, should never be promoted by any drastic cathartics 
nor neutral salts, but those nutriments which experience has proved 
to be constipating should be avoided, and a free use made of those that 
are known to possess slightly-laxative properties. From the earhest 
time to the present, it has been a subject of dispute whether scrofulous 



DISEASES OF THE NERYOUS SYSTEM. 357 

affections, particularly humid eruptions of the head and face, have any 
connection with hydrocephalus, for almost all the children of tuber- 
culous parents suffer from these cutaneous eruptions. Formerly it was 
unanimously conceded that they ought not to be treated except so far 
as cleanliness demanded, for it was observed that, after a certain time, 
occasionally not till after many months, these eruptions ceased to dis- 
charge, formed dry crusts, and when these fell off the normal cutis was 
seen beneath free from any visible cicatrix. There is no doubt that our 
predecessors in therapeutics, who were indisputably more officious 
than the present generation, and knew as well as we do that the cure 
of an impetigo is very much promoted by solutions of nitrate of silver 
and corrosive sublimate, by lead-water, and zinc-ointment, came 
through unpleasant experience to the conclusion that it was safer to 
discard these decidedly efficacious remedies. Of late, such a precau- 
tion has generally been regarded as disadvantageous, and scrofulous 
eruptions of the head are removed as quickly as possible, a practice 
which I too favored for a long time. But it has happened to me 
twice that children, in whom extensive eruptions of the head dried 
up suddenly, were at the same time attacked by hydrocephalus. 
Consequently, since that time, I have entirely renounced this desiccat- 
ing treatment. Of course, I do not intend to declare that there is an 
actual connection between eruptions on the head and acute hydro- 
cephalus, for to establish such a connection those two cases are by no 
means sufficient, and may be contradicted by many hundred others, in 
which the eruption of the head dried up rapidly without being followed 
by any ill effects. But, since it has also been proven by an equal ex- 
perience that they heal spontaneously without any thing at all being 
done for them, it follows that an expectant treatment will probably do 
no harm, and that possibly something beneficial might, in the end, be 
gained by it. 

But what treatment are we to institute when the first symptoms 
of hydrocephalus have actually appeared ? The answer may be readily 
divined by recalHng what was said as to the prognosis. In few diseases 
is it possible to pronounce all remedies so positively ineffectual as in 
the one under consideration ; and, if in the remainder of this section the 
various methods of treatment hitherto proved to be useless are but 
briefly described, it is not with the intention of challenging observa- 
tion, but rather for the purpose of showing the therapeutist how much 
has already fruitlessly been tried in this fatal disease. 

In the first days of the disease, derivatives upon the skin are in 
special favor ; a seton in the nape of the neck, large pea issues in the 
arms, a blister kept in a constant state of suppuration, pustulating 
ointments of tart, emetic or sublimat., cauterizations with potassa 



358 DISEASES OF CHILDREN. 

fusa, all serve tlie same purpose, to wit, to produce a severe cutaneous 
irritation, with as profuse subsequent suppuration as possible. 

That the antiphlogistic method of treatment has been employed with 
various degrees of ^-igor, and in every stage, is well known. Leeches 
have been applied to the temples, behind the ears, on the nape, at the 
anus, between the thighs, and large or small venesections in the arm, 
foot, and jugular vein. Ligature of the carotids even has been pro- 
posed, but I am not aware of its ever having been performed. 

The apphcation of cold has also been tried in various ways. The 
ordinary cold-water compresses are constantly kept on the sheared or 
shaved scalp, a bladder filled ^vith ice is laid upon the head, the head 
is washed or douched two or three times in the hour with cold water, 
and an apparatus even has been invented for the purpose of keeping 
up an uninterrupted irrigation. To the first measures there is nothing 
objectionable, but the irrigation plan is an altogether too elaborate for 
practice. 

" For this purpose," according to Bouchut^ " the neck of the child 
is wrapped around by a water-proof cloth, which communicates with a 
gutter on each side of the bed. A thin stream of water is allowed to 
ilow down upon the head of the child from a reservoir suspended over 
it, and is carried off in the gutters above mentioned." Whether 
hydrocephalic children will quietly submit to be thus showered, is 
not stated, but to me it appears extremely improbable. 

Among the remedies capable of bringing about an absorption of 
the deposited exudation, mercury and iodine rank first, and the diu- 
retics next. Of mercurial preparations, blue ointment, corrosive subli- 
mate, and calomel, are most frequently resorted to ; the last two are 
given in large doses, so as at the same time to operate on the bov\'els. 
Even tartar emetic, as high as several grains daily, has been adminis- 
tered as a general alterative remedy. Phosphorus also has been tried, 
on account of forming one of the component parts of the brain. Of the 
diuretics, nitre, digitalis, squills, and juniper — of the antispasmodics, 
assafoetida, camphor, moschus, castoreum, have been used. Li restless, 
delirious children, opium has been given with marked tranquillizing 
effect, but the majority of physicians dread the paralyzing action of 
this remedy, and too readily believe that the steadily-increasing 
deterioration of the patients is in part caused by the opium. But he, 
who has seen a number of such cases perish without narcotics, will 
administer opium, or, still better, morphine, without timidity and with- 
out suffering any compunction of conscience, in cases of gTeat restless- 
ness and severe headache. 



DISEASES OF THE NERYOUS SYSTEM. 359 

The sliort but extremely sad resum'e of tlie whole treatment then 
is, that at first the treatment, as for a simple, non-tuberculous 
meningitis, is mildly antiphlogistic, with small doses of calomel, 
blue ointment, and cold ablutions of the head, and perhaps also by 
the application of moderately-active cutaneous irritants, and nervous 
excitement is tranquillized by morphine. Torturing, violent applica- 
tions are to be avoided entirely, for their inefficiency has often enough 
been made evident, and it is admitted that methods of treatment 
which torture are only permissible when there is any hope of benefit. 
And yet, in a disease that is universally regarded as fatal, all possible 
therapeutic experiments are practised. 

(2.) Mexixgitis Simplex, Pueulenta, an"d EjS^cephalitis — 
(Simple Inflammation of the Meninges and the Brain). — Although 
chronic hydrocephalus very naturally ranges itself with the acute, still 
a few words may be said here of simple meningitis, on account of the 
many analogies between it and the preceding disease. 

It is a much rarer afi'ection than acute hydrocephalus, and occurs 
no oftener in children than in adults. In this disease, portions of the 
brain proper in proximity with the meninges almost always are in- 
volved, and, as inflammation of the meninges cannot be clinically 
distinguished from congestion and inflammation of the cerebral sub- 
stance proper, it is, therefore, best to 'describe these different morbid 
processes in one clinical discourse. 

Etiology. — Occasionally the causes of this disease can be ascer- 
tained with great accuracy. The usual causes are traumatic — cere- 
bral concussion, which, on account of the liveliness and awkwardness 
of the child, often enough occurs, injuries acting directly upon the 
cerebral substance, great heat and cold, insolation, immoderate mental 
exertions, and the propagation of inflammation from adjacent organs. 
The most frequent cause in this respect is otorrhoea ; less frequently 
the meningitis takes its source from an ozoena, or from an inflammation 
within the orbital cavities. Meningitis also occurs after erysipelas, 
but, in the majority of instances belonging to this class, the erysipelas 
seems to be of a traumatic nature, and hence a purulent absorption 
through the osseous vessels must be assumed. Those cases of menin- 
gitis following metastases, repercussed cutaneous eruptions, sup- 
pressed epistaxis, etc., are mostly problematical, though even for these 
some very reliable vouchers are found in medical literature. At cer- 
tain times this disease has been seen to appear in an epidemic form. 

Pathological Anatomy. — The dura mater participates in the in- 
flammation in traumatic cases only, and in these the morbid process 
always remains circumscribed, and produces a flat, fibrinous, or purulent 
layer of exudation upon that membrane. In chronic cases, which in 



360 DISEASES OF CHILDREN. 

children are very infrequently observed, the dura mater becomes 
markedly thickened, and thrombi form in one or the other of its 
sinuses. In simple meningitis the inflammatory exudation is located 
between the arachnoid and pia mater, and penetrates deep into the 
convolutions and depressions of the brain. As an important distinc- 
tion from tuberculous meningitis, it is never found so dijBFased over 
the base of the brain as upon the upper surfaces of the hemispheres. 
It, however, extends down over the spinal cord, and thus adding men- 
ingitis spinalis. The exudation is yellow, yellowish green, fibrinous, 
or purulent, and is scarcely ever more than a hne in thickness. It is 
either bathed in a large quantity of turbid, opaque serum, in which it 
often liquefies, and then becomes converted into a flocculent, greenish, 
glittering fluid, or it is poor in serum and rich in fibrin, so that, when 
the arachnoid is pulled ofi", this false membrane partly remains hang'- 
ing on to the arachnoid membrane and partly to the brain. The pecu- 
liarity is also worth mentioning, that acute hydrocephalus never occurs 
in combination with simple meningitis, but invariably supervenes upon 
tuberculous basilar meningitis. This is due undoubtedly to the fact 
that in the former the direct continuation of the pia mater into the 
cerebral cavities is free ; in the latter, on the contrary, only the base 
of the bram becomes the site of the gelatinous mass of exudation. 
The outer stratum of the brain-substance may be involved and soft- 
ened, or it may be in a perfectly normal condition. 

This simple meningitis, which occurs in an extremely acute form, 
though generally terminating fatally, cannot, we may judge from 
the distinct traces of resolution occasionally found, be regarded as 
a hopeless disease. In the favorable cases the exudation becomes 
transformed into a fibrous structure, the pia mater into a milk-white, 
firm membrane, and becomes united with the cerebral cortex on the 
one side, and with the arachnoid on the other. 

Symptoms. — Simple meningitis, when it is not of a traumatic 
origin, or is the result of an otorrhoea, attacks almost exclusively 
well-nourished, robust children, which bear no trace of scrofula. In 
cretins, who are not infrequently victims of this disease, the autopsy 
exhibits, conjointly with the old hypertrophies of the meningitis, a 
freshly-deposited exudation, so that the fatal disease in such case 
must be regarded as a relapse of the former meningitis. The com- 
mencement of the disease is extremely acute, and, by the second or 
third day, the process has already attained to its climax. All the pro- 
dromata that have been described in connection with hydrocephalus 
acutus are totally absent here. But a hydrocephalus that has already 
reached its acme can no longer be diagnosticated from a meningitis 



DISEASES OF THE NERVOUS SYSTEM. 361 

of the hemispheres, and only the course of the two diseases furnishes 
the requisite data for a differential diagnosis. 

In simple meningitis, as well as in the tubercular form, vomiting 
without retching, constipation, slow pulse, unrhythmical respiration, 
violent headache, retracted abdomen, and the whole train of nervous 
distm-bances which have been more minutely detailed in the preced- 
ing section, occur. The following distinctions, however, may be made 
available : The course of meningitis simplex is more rapid, for death 
usually ensues between the third and sixth day after the invasion of 
the disease, and the temperature of the skin, particularly on the head, 
is correspondingly more elevated. The delirium is extraordinarily 
severe, even furious ; the face has a wild, confused expression, and the 
compulsions and contortions of the body are of extreme severity. The 
pulse is less retarded than unrhythmical, the vomiting is not so con- 
stant, and may even be entirely absent. 

When such children do not succumb to the meningitis in the first 
few days, the symptoms will abate very gradually, and recovery may be 
hoped for ; but, as the diagnosis between the disease under consideration 
and acute hydrocephalus is difficult, recovery must continue extremely 
doubtful. A marked emaciation supervenes, and a mental weakness 
is liable to follow, a result which I have twice witnessed in my own 
practice. The great similarity in the termination of meningitis and of 
hydrocephalus makes the assertion, that acute hydrocephalus is some- 
times curable, quite excusable, for it is indeed possible, although very 
improbable, that children of tuberculous parents may exceptionally 
acquire a simple meningitis, from which perchance they may recover. 

Treatment. — In this disease, a mercurial treatment is decidedly 
effectual, the two children which I saw recover having been treated 
exclusively with mercury internally and externally. For this purpose, 
a drachm of blue ointment is rubbed in daily upon the sheared head, 
and gr. ss. of calomel is given every hour. In both children the dis- 
ease had reached a most critical degree, as evinced by cerebral vomit- 
ing, ujirhythmical pulse, retracted abdomen, and convulsions. Severe 
stomacace supervened, however, on the third day, and, immediately 
upon that, a gradual abatement of all the symptoms followed. Cold 
affusions of the head, repeated every two or three hours, exercise a 
very favorable influence upon the delirium. These are best performed 
by wrapping the breast and arms of the child in a shawl or cloth, the 
head is then held over a basin, and cold water is poured upon it from 
a moderate height for one or two minutes. A mitigation of the cere- 
bral symptoms, although only temporary in its duration, always fol- 
lows this proceeding. 



362 DISEASES OF CHILDREN. 

Five children I treated Tvitli leeches, but all succumbed to the disease. 
As sudden blanching of the lips and rapid pulse followed the loss of 
blood so directly, they were regarded as the effects of this procedure. 
On the other hand, in those two children which recovered, no leeches 
were employed, and therefore, according to my own experience, I 
have to regard the treatment without leeches as the correct one. The 
stomacace and salivation, occurring as the effects of mercury, cannot 
be regarded as critical, though they may appear in cases which termi- 
nate fatally on the second day. Generally, it is easily recovered from 
hj the administration of chlorate of potassa, of which a drachm, dis- 
solved in several ounces of water, may be consumed every day. 

Some maintain that, in cases of great excitability, opium should 
be used in combination Avith mercurials, but I am unable to approve 
of this ; on the contrary, my experience leads me to consider narcotics 
as contraindicated in this terrible disease, which rapidly destroys by 
paralysis. I am the more opposed to the use of narcotics, that we 
possess in cold such a valuable remedy against the excitability. 

Compression of the carotids Avith the thumb and index-finger 
against the spinal column, or the lateral walls of the larynx, for a 
minute or two, repeated several times a day until the head symptoms 
abate, has been highly recommended in France. 

That this compression, when feebly executed, is only an illusory 
remedy, and when forcibly performed is apt to compress the jugular 
vein rather than the carotid artery, and thus in the end do more harm 
than good, has been conclusively proved by jS. Leicis. This measure, 
therefore, has nothing but an historical interest. 

The marked emaciation, which is the result of a meningitis, 
must be treated by a nourishing diet, by stimulants, iron, quinine, etc. 
For the mental weakness, which this disease in most cases leaves be- 
hind, there is no other remedy, to my knowledge, than mental rest, 
along with a tranquilhzing, psychical treatment. 

(3.) I]S"SOLATio — SuxsTEOKE. — Insolation may next engage our 
attention, very properly ranking next to purulent meningitis, although 
the pathological anatomy exhibits no direct connection between the 
two diseases. In the former no purulent effusion is found upon the 
meninges, only intense injection, a slight augmentation of the reddish 
contents of the ventricles, and softening of the cerebral substance. 

Symptoms. — Children who, with uncovered heads, have exposed 
themselves for some time to the direct rays of the sun, return to the 
house with flushed face, reddened neck and arms, and soon complain 
of an intense headache. The red color of the parts of the skin men- 
tioned does not disappear, as after simple overheating, but remains for 
many days in the shape of small, elevated erythematous spots. After 



DISEASES OF THE NERVOUS SYSTEM. 

several liours delirium comes on, often of a violent nature, with the 
development of an excessive muscular power, flushed face, injected 
ejes, contracted pupils, strong pulsation of the carotids, hot skin, dry 
tongue, and intense thirst. With this array of symptoms, a severe 
meningitis may well be suspected, but the pulse is very much accel- 
erated, and, in the majority of cases, rhythmical, while in the puru- 
lent meningitis it often becomes retarded, and sometimes is un- 
rh3rthmical. Vomiting also is absent, unless undigested food exist 
in the stomach. 

The course of insolation is quite difi'erent from meningitis. After 
a half a day to at most two days, all these symptoms disappear. The 
child, at first, falls into a restless, then into a profound sleep, and 
wakes fi-om it with, complete consciousness, and, at the end of two or 
three days more, the health is fully reestablished. But instances have 
occurred where death took place at the very commencement of the 
attack. These cases, however, form the exception, and are rarely met 
with in our moderate climate. 

Treatment. — Venesection, it is true, produces some abatement of 
the symptoms, but, in consequence of the furious delirium, it is im- 
possible to perform the operation, and the use of leeches is opposed 
by the same condition. The best and quickest means is always to 
cut the hair as short as possible with a few sweeps of the scissors, 
and then apply the cold douche to the head every hour. This pro- 
cedure invariably produces a decided moderation of the furious symp- 
toms. Ice may be applied to the head, sinapisms to the extremities, 
calomel and jalap may be given internally, and stimulating clysters 
administered. Almost all children recover from this seemingly ex- 
tremely dangerous condition. 

(4.) Hydeocephaloid and Ieritatio Ceeebei. — Ifarshall Hall 
found some resemblance between acute dropsy of the head and the 
symptoms originating in atrophic children due to anaemia, and on that 
account called the latter condition hydrocephaloid disease. This dis- 
ease, although in no way based upon pathological anatomy, has been 
admitted into all the text-books, and I shall therefore also give it a 
brief discussion here. Although it is not a distinct disease, but rather 
a termination of such, still, the name deserves to be retained, if it were 
only for the sake of convenience, in order to describe a whole group 
of symptoms by one word. By irritatio cerebri, therefore, is under- 
stood almost exclusively those cerebral symptoms which commonly 
supervene in consequence of interrupted nutrition, or of atrophy, so 
that the symptoms of hydrocephaloid and of irritatio cerebri maj', with 
the utmost propriety, be considered together. 

Symptoms. — After various exhausting diseases, generally such as 



364 DISEASES OF CHILDREN. 

diarrlioea, abstraction of blood, etc., children under one year of age are 
seized with a class of cerebral symptoms which, at first sight, without 
due reflection, might certainly give rise to the thought of a material 
alteration, an exudation in the brain. The most striking of these 
symptoms is an incessant rubbing to and fro of the head, or a boring 
of it into the pillow, by which the occiput is wholly deprived of hair, 
and small abrasions of the scalp, loss of epidermis, and furunculosis 
often result. Many children also pluck the head with their hands, 
pull the hair and ears, and scratch their faces until they bleed, and 
cease to notice the objects by w^hich they are surrounded. The eye- 
lids are half closed, and, in the majority of cases, the globe is rolled 
upward. The upper extremities are in a constant state of rigid flexion. 
The thumbs are dra^vn into the palms, and the fists closed so firmly 
that considerable strength is requisite to open them, and the palms 
of the hands become denuded of epidermis. This latter sign is espe- 
cially observed in children who frequently handle the fermenting 
sugar-teat. The lower extremities are likewise rigid, either extend- 
ed or contracted, and the muscles of the nape of the neck are so firmly 
contracted that, if the child be laid upon his side, the body will curve 
far backward. Occasionally, particularly toward the latter end, te- 
tanic spasms supervene. Almost all these children vomit immediately 
after food or drink has been administered — a fact which gives this 
disease a resemblance to an exudative cerebral affection. It is also 
true that this vomiting occurs without retching or exertion (as is gen- 
erally the case in young children), but it has its foundation in an irri- 
table state of the gastric or intestinal mucous membranes. On ex- 
amining the heads of children, who, in consequence of profuse 
diarrhoea, have become atrophic, and in whom these cerebral symp- 
toms have appeared, the temperature will be found to be elevated, 
the anterior fontanel depressed, the cranial bones overlapping each 
other ; in short, all the signs of such an extremely aggravated state of 
cerebral atrophy that we are enabled with the utmost certainty to 
prognosticate a fatal termination. Constipation is of more frequent 
occurrence than diarrhoea ; but, should the latter exist, it is never 
copious ; the appetite, in most cases, is slight, though sometimes a 
wonderful greediness comes on, and continues almost till death. The 
pulse, unhke that in genuine hydrocephalus, is extremely rapid, and 
the respiration, although unrhythmical, still almost always perceptibly 
accelerated. At first, the child will cry incessantly for several days 
and nights ; toward the end it is only able to utter a low groan, or 
single abrupt cries. 

Autopsy. — The brain is found softened and watery, the gray sub- 
stance pale and not sharply defined, but passes gradually into the 



DISEASES OF THE NERVOUS SYSTEM. 365 

white portion. The meninges are infiltrated with serum, and in the 
ventricles onlj the normal amount of fluid is found. It is probable 
that the quantity of fat in the brain has become decidedly diminished, 
and in this manner the cerebral symptoms may be explained. I am 
not aware that any chemical investigations have been instituted in 
this direction. 

Treatment. — Every thing that has already been recommended in 
the treatment of intestinal catarrh and enteritis foUiculosa is appli- 
cable here ; and the reader is therefore referred to that section. To 
counteract the continuous crying and sleeplessness, cold ablutions of 
the head, apphed by the naked hand, the keeping of the body dry 
and warm, are, as yet, the only means worthy of recommendation. 
After the ablutions, rest for one or more hours usually ensues. The 
only active remedy capable of restoring such an extremely prostrated 
nutrition is, the breast of a healthy wet-nurse, the only precaution 
necessary to take being, not to wean the wet-nurse's child until the 
sick child is able to suck, wliich will often take several days. The 
necessary consequence of neglecting this precaution would be to sub- 
ject the wet-nurse to sickness, a mastitis, or a suppression of the milk. 

(5.) Hydrocephalus Cheokecus (Chronic Dropsy of the Head). 
— Theoretically, an external and an internal^ a congenital and an ac- 
quired chronic dropsy of the head are distinguished. Practically, how- 
ever, these forms cannot be separated from each other, for it is impos- 
sible to assert, especially as regards the latter distinction, whether the 
child came into the world with a small effusion which subsequently 
increased markedly, or whether it was first formed perfectly normally, 
and only latterly became hydrocephalic. The external dropsy of the 
head is almost always congenital, and usually complicated with hernia 
of the brain, and on that account will be returned to further on. 

Pathological Anatomy. — The most extensive effusion into the 
ventricles takes place in the foetus, and the delivery often becomes 
impossible till perforation has been resorted to. In congenital dropsy 
of the head, the quantity of the water may increase to several pounds, 
according to some authors even to ten pounds. The ventricles are 
distended into large sacs, and their upper walls so attenuated that 
they rarely measure a line in thickness, or they may be reduced 
to so thin a covering that it is impossible to dissect it off. The con- 
volutions of the cerebrum are faintly marked on the upper surface of 
the brain, may be perfectly smooth, and the meninges extremely at- 
tenuated. The deformity of the cranium corresponds wdth the quan- 
tity of water within it. The ossification of the cranial bones, naturally, 
is very much retarded, the sutures become Avide enough to admit a 
finger, and the anterior fontanel attains a diameter of several inches. 



3G6 DISEASES OF CHILDREN. 

Should life last for several years, an ossification finally takes place ; it 
is effected by the bones sending out from their borders long radiating 
projections toward each other till they become united, and thus form 
excavated shallow sutures between them ; or, finally, they may be 
united by a number of ossa triquetra becoming developed in the fon- 
tanels and between the separated bones. As these forms of union 
never proceed uniformly, one suture becoming closed on one side 
earher than upon the other, marked malformations of the skull result, 
to which Yirchoio in particular has directed his attention. The most 
common abnormalities deserving to be mentioned are, the immoder- 
ately long, broad, high, round skull ; the blunt, quadrangular cranium ; 
and the cranium that slopes in the direction of the transverse or lon- 
gitudinal diameter. The efi"used fluid acts no less strikingly upward 
than it does downward. The corpus striatum and optic thalami are 
flattened and forced asunder by the dilatation of the third ventricle, 
while the floor of the latter is very much attenuated and has become 
transparent. The corpora quadrigemina, through the same cause, are 
flattened, the commissures mangled and attenuated, the crura cerebri 
forced asunder, and the septum ventriculi broken through in many 
places. The cerebellum is diminished, out of proportion to the cere- 
brum, and flattened ; also the pons Varohi and the pineal gland. 

In acquired hydrocephalus^ or that variety which develops itself 
in children who, from several months up to many years of age, enjoy 
a perfectly normal physiological development of the skull, the morbid 
alterations are less strildng. The quantity of the serum in these 
cases depends upon the formation of the cranial bones ; whether any 
and which sutures are ossified ; and whether, at the commencement of 
the accumulation of fluid, a divergence of the bones can take place. 
The quantity of serum in these cases does not generally amount to more 
than from three to six ounces, and the alterations of the shape of the 
skull and brain, of course, never become so marked as in the congen- 
ital dropsy, which, after birth, continues to grow rapidly. The de- 
scription of the external forms of the skull will find a more appropriate 
place in the section on Symptomatology. 

Among the causes of chronic hydrocephalus, neoplasms in par- 
ticular deserve to be mentioned, by which a sinus is made impermea- 
ble, and thus the accumulation of the serum is produced. Certain 
other complications, which could be brought into direct connection 
with hydrocephalus, tuberculosis particularly, so common in the acute 
form, do not here exist. 

The chemical analysis of the efiused fluid has taught us that 
the dropsical serum possesses ^-ery similar properties to that of acute 
dropsy of the head. Its reaction is alkaline, a trace of albumen is 



DISEASES OF THE NERVOUS SYSTEM. SQ7 

found, and the proportion of potassium to sodium is different from 
that found in the blood-serum. This subject is treated in detail at 
page 341. 

Symptoms. — On examining the skull, marked deviations from the 
normal form are found. The earlier the hydrocephalus begins, the larger 
will the cranium become ; it is largest where the process begins in 
utero^ and smallest in the cases occurring after closure of the sutures. 
The earlier the exudation, or, more correctly speaking, the augmenta- 
tion of the physiological exudation of the fluid contents of the cere- 
bral cavities, occurs, the more pronounced will be the globular form 
of the skull ; the later this happens, the less will be the deformity. 
If some of the sutures have become ossified, while others are still in a 
distensible condition, the skull w^ill always be elongated in the direc- 
tion of the closed suture. For the purpose of making the case com- 
plete, it is well to institute measurements of the enlarged skull, by 
which the largest circumference (that which passes over the frontal 
prominences), the distance from one ear to another, and from the pro- 
tuberantia occipitalis externa to the root of the nose, may be ascer- 
tained. Practically these measurements have but little value, for the 
arching of the forehead and the attitude of the temporal bones fur- 
nish suflBciently accurate data by which to judge of the degree of the 
abnormal enlargement. They may, however, serve to instruct us as to 
the rapidity with which the disease progresses, for thereby it is strik- 
ingly seen that the distention of the cranium does not take place uni- 
formly and gradually, but by fits and starts, the disease often being at 
a stand-still for long intervals. If the anterior fontanel is still ununited, 
as is the case in most instances, it will become distended to a great 
vault of several inches in diameter, will fluctuate distinctly, and feel 
tense. This arching and tension always continue until death, even 
when the body in general is very much emaciated. The synchronous 
rising of the fontanel with the pulsation of the radial artery can be 
very strikingly noticed, while its elevation and depression with the 
respiration are totally abolished. Great attention has been for some 
time bestowed upon the auscultation of the anterior fontanel, and it 
has certainly been clearly shown that a slight breathing or blowing 
murmur is perceived over various places on the skull, particularly over 
the large fontanel of rachitic children, but never heard in hydrocepha- 
lus. It is very easy to understand why these blowing murmurs dis- 
appear in cases of hydrocephalus, as they most probably originate in 
the unequal sinuses of the dura mater, and these must become seri- 
ously compressed by the increasing quantity of the water within the 
skull. The best index is the position of the temporal bones. AYhile, 
in the healthy child, they stand perpendicularly, in the hydi-ocephalic 



368 DISEASES OF CHILDREN. 

child they diverge greatly at the upper part, so that, in extreme cases 
of serous distention, the auricle is hid from view when looking down 
upon the head. After the disease has existed for some time, the up- 
per wall of the orbit, through the continuous pressure of the brain, be- 
comes flattened, and, as a result of this, the eyeballs protrude more 
and more, until the whole cornea, and even the upper segment of the 
sclerotic is exposed, a condition that gives a peculiar glaring and un- 
natural look to the features. From the same cause, augmented press- 
ure within the skull, a strong collateral circulation occasionally also 
forms in the scalp and frontal integument, the distended vessels ap- 
pearing as tortuous blue cords. This discoloration produces a singular 
appearance. The face, as contrasted with the dimensions of the ver- 
tex, appears extremely diminished, but, aside from that, retains its 
normal proportions. In most cases in young children, with congenital 
hydrocephalus, it is very lean, sharp, and has a senile appearance ; 
while in older children it may remain plump and round until death. 

The functional disturbances are numerous, and vary in almost 
every case. In the acquired form these symptoms come on either 
very gradually, or are ushered in by a fever and a few phenomena, 
such as occur in acute hydrocephalus — outcries, vomiting, headache, 
gnashing of the teeth, and dehrium. The mental capabilities some- 
times remain unaffected for a remarkably long time, and it is sad 
to behold the little sufferer, who, with a monstrous head, suffering 
involuntary fecal and urinary evacuations, with limbs paralyzed or 
contracted, yet answers all questions rationally, and even reasons 
acutely. In some cases, however, mental aberration is among the 
early symptoms, ending in imbecility. Of the senses, that of vision 
most frequently disappears first. The pupil becomes moderately 
dilated and fixed, and the sensibility to light so totally lost that 
children will gaze for a long time, and sometimes prefer to look 
directly at the sun. Strabismus is of less frequent occurrence in 
this form than in the acute hydrocephalus. A nystagmus of one 
or both eyeballs is oftener observed, and the pupils at times are 
unequally contracted or dilated. The other senses, in most cases, 
remain up to a brief period before death ; this is especially true 
of the sense of hearing. The sensibility of the skin is diminished 
or abolished, especially in the paralyzed extremities. Hemiplegia 
occurs less frequently than bilateral paralysis, the lower extremi- 
ties being the most frequently affected. This is followed by an 
insensibility, then a paralysis of the sphincters of the bladder and 
rectum, thus making the care of these children extremely laborious. 
Bed-sores are unavoidable ; yet, as they fortunately accelerate very 



DISEASES OF THE NERVOUS SYSTEM. 3^9 

mucli the termination of the little patient's suiferings, are blessings in 
disguise. Contraction of the muscles is of frequent occurrence ; con- 
\nilsions are occasionally observed, and death may occur during a fit. 
The remainder of the phenomena, which characterize an attack of acute 
hydrocephalus, as a rule, are absent in the form of disease under con- 
sideration. Tlie respiration, which, in the former, is distinguished by 
the absence of the rhythm, in the latter is normal ; likewise the re- 
tardation of the pulse is not ordinarily met with here. The digestion 
may remain perfectly normal, no vomiting and no constipation ensu- 
ing ; or, if they do occur, they are only temporary. This explains 
the continuance of a good state of nutrition sometimes for years. If 
no other disease, such as tuberculosis or intestinal catarrh supervene, 
the nutrition will not be impaired ; the appetite often becomes of a 
voracious character. The adipose tissue of the body becomes abnor- 
mally augmented. The patient complains only temporarily of head- 
ache, and febrile attacks are often due more to accidental intercurrent 
affections than to hydrocephalus per se. Acute accessions may cause, 
for a few days, the very picture of an acute hydrocephalus, still the 
deterioration does not progress as incessantly as in this latter condi- 
tion, for a stasis occurs in the critical symptoms, and the disease 
again assumes its chronic character. 

Tlie course^ as may already have been inferred from the preceding 
history, is of a chronic nature. Large congenital dropsies of the 
head are quickest terminated ; they, indeed, are exposed to the great- 
est danger during the delivery, and only very exceptionally endure 
the injurious effects of pressure during that act. Very moderate 
effusions, which have been acquired much later, are tolerably well 
borne for many years, and such persons may attain to a middle age ; 
indeed, a case of hydrocephalus is recorded which died at the age of 
fifty-four years. 

Death may occur as an immediate effect of the cerebral lesions, 
from convulsions or increasing coma and collapse, where, at the au- 
topsy, fresh meningitis or meningeal hasmorrhage may be found con- 
jointly with the effusion. Bed-sores and their sequelae, pyemia and ex- 
haustion, may furnish the next cause. The subjects, in the majority 
of cases, however, die from intercurrent affections, chiefly from intes- 
tinal catarrh and enteritis folliculosa, or during dentition, from pneu- 
monia, meningitis, or an acute exanthema. These affections in chronic 
hydrocephalus oftener terminate fatally than in previously healthy 
children. 

The differential diagnosis in the well-pronounced cases has no 
difficulties, a diagnostic error being wholly improbable. Small col- 
lections of water, on the contrary, by no means furnish very strildng 
24 



370 DISEASES OF CHILDREN. 

symptoms, and may be very easily confounded with rachitis of the 
skull, or with simple hypertrophy of the brain and of the cranial bones. 
The main distinction between chronic hydrocephalus and rachitis of 
the skull consists in this, that the temporal bones in the former are 
always directed outward, while in the latter disease they stand per- 
pendicularly, even when the anterior fontanel has become very large. 
All the hydrocephalic functional symptoms are absent here, and the 
attenuation of the skull itself generally is not found diffused over the 
whole surface, but confined to the posterior parts, while the frontal 
bones display the usual rachitic hypertrophy, and the remaining por- 
tions of the skeleton, thorax, and extremities, are similarly affected. 
Cerebral hypertrophy is likewise unaccompanied by any of the hydro- 
cephalic symptoms. It almost always originates in consequence of 
rachitis of the skull, and the bones are markedly hypertrophied. But, 
after all, we are entirely unjustified in speaking of hypertrophy of the 
brain from mere eye measurements, so long as no accurate weighings 
of the brain, in comparison to the entire weight of the body, have 
been instituted, and the medium number fixed upon. 

Therapeutics. — I know, indeed, certain children with chronic hy- 
drocephalus, in whom no augmentation of the serous effusion has 
taken place for years, and who are in a tolerably good state of men- 
tal and corporeal development, but that an actual cure ever was accom- 
plished, so as to secure the social usefulness of the patient, we have no 
proof. To keep these children alive as long as possible, they must be 
carefully nursed, and their diet accurately regulated. Though the ac- 
tion of diuretics in promoting the absorbing of the hydrocephalic fluid, 
and its subsequent elimination, seems to be extremely problematical, it 
appears proper to give them. For this purpose such only should be 
chosen as exercise no general weakening influence, for example, 
juniper, digitalis, acetate of potash; iodide of potassium, mercury, 
tartar emetic, and drastics generally, are to be avoided. A tonic and 
stimulating treatment cannot be injurious, particularly when proper 
attention is at the same time paid to the condition of the bowels. 
Locally, the most various ointments and fomentations have been em- 
ployed, and, so long as the children are not tormented with them, 
they are not objectionable. The continuous strapping of the head for 
years with adhesive plaster, so warmly recommended by Englemaiin^ 
as well as the puncturing and evacuating of the contents of the ven- 
tricles in those cases where the fontanels are still unclosed, has been 
tried by a few surgeons eager to operate, and has been abandoned 
because of its total inefficacy. 

(6.) E]S"CEPHALOCELE (Congenital Hernia of the Brain). — Her- 
nia cerebri is always congenital, and produced by an immoderate dis- 



DISEASES OF THE NERVOUS SYSTEM. 371 

tention of the brain, as an effect of which the proper development of 
the cranial bones cannot take place. In these cases a tumor is found 
immediately after birth on some part of the skull, most frequently in 
the occipital region, and, on examining the parts more closely, the 
bones will be found to be annularly defective. The size of this 
tumor varies between that of a child's head and a small nut, and 
chiefly consists of the water which in all cases surrounds the pro- 
lapsed portion of the brain. The narrower the bony chasm, the more 
pediculated will be the tumor ; and the wider it is, the more flattened 
the prolapsed part will be. Its covering consists of an atrophic, hair- 
less cutis, which is united with the pericranium and the meninges. 
In large hernia, the integument may be so atrophied that the sac 
bursts from pressure at the delivery, whereupon death is the imme- 
diate result. Hernia cerebri occurs most frequently at the occijDut, 
upon or beneath the posterior fontanel. It also occurs at the root of 
the nose, or angle of the eye, at the anterior fontanel, and very rarely 
through the temporal bones. When it makes its exit at the root of 
the nose, the nasal bones will be found forced asunder, and the dis- 
tance between the eyes increased. 

By compression the tumor may be entirely reposited, or consider- 
ably diminished, but the procedure always induces pain, and, when 
the jDressure is kept up, may give rise to cerebral phenomena, such as 
convulsions, tetanic s^^asms, stupor, and syncope. In small tumors, 
with tough coverings, an early death is by no means an absolutely 
necessary occurrence. But the growth of the tumor, which always 
keeps pace with the other portions of the body, exposes it to almost 
unavoidable contusions and other injuries, which give rise to a chronic 
meningitis, and thus it happens that it is one of the rarest occurrences 
to meet with an adult or a child with hernia cerebri of several years' 
standing. Although life, with very great care and attention, may be 
preserved for a few years, still, the mental developments remain very 
much retarded, and imbecility is invariably the result. 

Treatment. — In very small, entirely reducible herniae, a radical 
cure is said to have been effected by the continuous maintenance of 
the sac within the aperture till it is closed by bony deposit. When 
the reposition is not complete, as is generally the case, and when 
severe cerebral symptoms are induced by the reduction, we must be 
content mth simply protecting the dangerous spot from external 
injuries by a hollow piece of lead, or a properly-constructed leather 
covering. By this means the sufferer may live to an advanced age. 
Among the anatomical collections in this place, is a skull of an adult, 
on the occiput of which is an opening the size of a penny. The edges 
of this opening are round and smooth, and its history states that dur- 



372 DISEASES OF CHILDREN. 

ing life a cerebral hernia protruded through it. The removal, or the 
deligation of such a hernial tumor, according to Bouclmt^ always 
gives rise to a fatal meningitis. Consequently, the operation should 
be totally discarded. Better results may be expected from punctur- 
ing the tumor with a trocar, or, still better, with a simple needle in- 
troduced a number of times, and thus evacuating the contents. By this 
means we may often succeed in so diminishing the size of the tumor 
that a protective instrument may be applied, which otherwise would 
have been almost impossible. Though the secretion accumulates again 
after the puncture, the hernia, after the operation has been repeated 
six or eight times, remains permanently reduced in size, and a marked 
improvement in the whole condition is brought about. 

(7.) Sclerosis or the Beaijs". — Induration of the brain in chil- 
dren is extremely rare. Hilliet and Barthez^ and Weber ^ have reported 
single instances only. The sclerosis of children, like that of adults, 
either involves the whole brain, or only small portions ; the degree of 
induration fluctuates between an almost imperceptible hardness and 
a cartilaginous consistence. In the latter case, it is always combined 
with atrophy, loss of substance, and textural alteration. A slight 
degree of general induration occurs more frequently than any of the 
other forms, such as is sometimes found at the autopsy of fatal cases 
of scarlatina and typhus fever. The rarity of the partial induration is 
readily explained by the circumstance that cerebral apoplexy in child- 
hood is extremely rare, and that its resolution is the principal cause 
of this induration. In somewhat extensive meningeal haemorrhage, or 
purulent meningitis, the adjacent parts of the brain usually partici- 
pate, and the sclerosis then forms \he finale of these processes. These 
cases are characterized by an almost cartilaginous hardness, the indu- 
rated portions presenting a dirty, grayish-yellow color, which, to a 
great extent, takes the place of the gray substance, though the white 
substance also becomes more or less affected. Carcinoma of the brain, 
whose nature wdll be discussed in one of the following sections, should 
not be confounded with this induration. This cerebral sclerosis pos- 
sesses little else than anatomo-pathological interest, for the symptoms 
produced by it are not characteristic, and, consequently, no one is 
capable of diagnosing it. The symptoms it may occasion are epilepsy, 
idiocy, and neuralgia of various kinds. 

Treatment. — This must naturally be directed to the symptoms. 
The cure of the induration has never, to my knowledge, been accom- 
phshed. Narcotics, nervines, and tonics, will be the agents, ac- 
cording to circumstances. 

(8.) Neoplasms of the Bealn". — Adventitious growths are by no 
means of rare occurrence in the infantile brain. This is especially 



DISEASES OF THE NERVOUS SYSTEM. 373 

true of tubercles, whose effects are the more marked as they increase 
in size, and according to the rapidity of their growth. By the press- 
ure produced in this manner upon the surrounding cerebral parts, a 
general increase in bulk of the affected hemispheres takes place, and 
disturbances of the circulation are apt to ensue, which ultimately 
lead to cerebral oedema or effusion into the ventricles ; however, they 
are apt to occasion softening or small apoplexias in their immediate 
vicinity. The various forms of neoplasms, arranged in the order of 
their frequency, are — 

(a.) Tubercle. — The number of large tubercles in the brain is very 
limited, for usually they occur in twos or threes, and seldom more 
than five or six. The size varies according to the number, and 
usually fluctuates between a hazel and walnut. On the other hand, 
when a large number are found together, they are not apt to exceed 
the size of a pea. In form they always approximate more the round 
or oval, very rarely become agglomerated into irregular nodular 
masses, and, from this fact, it is supposed that tubercles probably 
embrace a certain space from the beginning, and do not subsequently 
become enlarged by external accretions. Tubercles have been found 
in all parts of the brain, still it cannot be denied that they are more 
frequently located in the gray substance than in the white. Hence, 
they are found either entirely at the periphery, or deep in the centre, 
where, as in the corpus striatum and optic thalami, much gray sub- 
stance exists. It is very rarely met with in the medulla oblongata, 
or in the septum or crura cerebri. Peripheral tubercles may be situ- 
ated so superficially that they touch the meninges and adhere to the 
dura mater, and so be confounded with tubercles of the meninges, 
which, however, never occur in this manner. If the tubercle itself is 
examined accurately, it will be found to present no differences from 
the large cheesy tubercle of the bronchial glands or of the lungs. It 
consists of a yellow, lardaceous, tough, friable mass, which, under the 
microscope, exhibits no cell-formation, but only amorphous granules 
and masses, in short, nothing but detritus. The parts by which they 
are immediately surrounded are vascular, and the union between- 
them and the cerebral tissue is not very intimate, for they may be 
entirely enucleated without any particular dexterity or trouble. 

The manner in which they originate is by no means clear, since 
only the fully-formed yellow cerebral tubercle is found, without any 
gray, crude, semi-transparent granules, such as it is possible to demon- 
strate in almost every tuberculous lung. It is true that EoJcitanslcy 
has occasionally found some portions of tubercles in this crude, jelly- 
like state, but he believes that the transformation must progress verv 
rapidly. Usually the whole tubercle forms a homoo-eneous mass, 



374 DISEASES OF CHILDREN. 

without any diflPerences in consistence or color ; still, occasionally, the 
commencement of softening may be detected, whereby the liquefied 
centre, or perhaps even the entire nodule, -will represent a capsulated 
ca\dty with sanious purulent contents. Microscopically the purulent 
mass which occurs here is distinguished from genuine pus by the 
absence of all cell-like structure, and the presence of simple detritus. 
No cretaceous tubercle is ever found in children, for a period of many 
years is necessary for the calcification of large tubercular masses. 
The most common complication, and at the same time most common 
cause of death, is acute miliary tuberculosis of the meninges, with 
acute hydrocephalus, which appears to originate through a direct 
absorption of the primary tubercles. The next complication as to 
frequency is tuberculosis of the bronchial glands and lungs. The 
reason why large, yellow, cerebral tubercles are found oftener in chil- 
dren than in adults is, that the adventitious growth, which probably 
is congenital, or acquired immediately after birth, may remain latent 
for some time, even for several years, without displaying any well- 
marked symptoms, though death commonly occurs during childhood, 
and on this account this pathological condition is but exceptionally 
seen in the adult. Cerebral tubercles produce no symptoms that are 
not produced by other neoplasms of the brain, and, in order to avoid 
repetition, all the s;)Tiiptoms occurring with them will be described at 
the conclusion of this anatomo-pathological expose of their character. 

(b.) Carcinoma. — Carcinoma of the brain, like carcinoma in gen- 
eral, is of itself extremely rare in children. I have met with it twice 
only in infantile cadavers. According to the statements of all authors, 
the medullary cellular form, " fungus medullaris," is the predominat- 
ing variety; the hard fibrous cancer scarcely ever occurs. Cere- 
bral carcinoma either infiltrates the brain, gradually disappearing in 
the normal cerebral substance, or it is sharply defined, of a round or 
oval form, and in these cases may be entirely enucleated with great 
ease. Usually it is a mass of considerable dimensions, and exists 
only in one hemisphere ; still, instances are related where nodules of 
cancer were found scattered throughout the entire brain. They have 
no preference, as in the case of tubercle, for the gray substance. ■ 
These carcinomata usually grow very rapidly ; they become somewhat 
flattened when they have reached the vault of the cranium, and may 
even cause atrophy of the bone, and make their appearance on the 
scalp ; or they may grow along the optic nerves into the orbit and 
attack the bulbs. They are often primary in the brain, and remain 
isolated in it ^\ithout simultaneously occurring in other organs. 

(c.) JEntozoa. — A few solitary cases are reported of encysted worms 
having been found in the brains of children. Echinococcus has been 



DISEASES OF THE XEKYOUS SYSTEM. 375 

found in the cerebral substance in the shape of large or small cysts. 
Cysticercus cellulosa occurs somewhat more frequently, and in most 
instances is at the same time present in large numbers in the muscles. 
The cysticercus, according to HoJcitansJcy^ is found almost exclusively 
in the gray substance, and preferably in the peripheral layers of the 
cerebral portion, where the cysts project above the level of the brain, 
and partly elevate the meninges. The animals may perish, and the 
cysts undergo calcareous degeneration, and a cretaceous substance will 
then be found enclosed in a capsule, and can be distinguished from 
cretefied tubercles with great difficulty. 

Symptoms. — It is one of the most inexplicable phenomena in pa- 
thology, that the symptoms of these neoplasms are by no means con- 
stant, and still more that, in a great number of cases, none at all are 
observed. Apparently perfectly healthy children are taken sick with 
acute hydrocephalus of the usual form, succumb to it in two or 
three weeks, and the autopsy reveals one or more large yellow 
tubercles in the brain, which may even be undergoing softening, hav- 
ing existed many months, perhaps years, without producing the slight- 
est symptom indicating their presence. In other cases, a prolonged 
and distinctly pronounced prodromatory stage is noticed, and the gen- 
eral signs of a chronic cerebral compression supervene. The child loses 
its appetite, vomits, and is attacked by unilateral or bilateral paralysis. 
The organs of sense become abolished, amaurosis, deafness, violent 
headache, convulsions, and contractions of the muscles, come on, and 
then the symptoms of meningitis usually terminate the sufferer's life. 
In most of the cases affected with the various kinds of carcinoma, 
there is intense headache, quickly followed by incessant restlessness, 
stuttering, weakness of the organs of sense, movements resembling 
St. Vitus's dance, onanism, convulsions, sleeplessness, paralysis, and 
exhaustion. In encysted entozoa, epilepsy, and chorea in particular, 
is frequently observed, and, in addition, the symptoms just described. 
The diagnosis of probable cysticercus can only be formed when, with 
the existing cerebral symptoms, the cysts of this entozoa can at the 
same time be found in the muscles, eye, and other parts of the body. 
Neoplasms of the brain are beyond the reach of therapeutics. They 
can, at the utmost, call for a symptomatic treatment only. 

(9.) Congenital Malfoemations. — Besides congenital hydro- 
cephalus and hernia cerebri already spoken of, a few other arrests of 
development occur, which are of interest to anatomy and to embryol- 
ogy only, as most of them are mere monstrosities. 

In this class we find acephalia^ or brainless and headless mon- 
sters. This condition is generally accompanied by spina bifida, ectopia 
of the heart, absence of the lungs and abdominal viscera, and distorted 



376 - DISEASES OF CHILDREN. 

extremities. There may, however, be only a deficiency of the brain, 
which may exist either in the longitudinal or transverse diameter. 
Thus hemicejDhalia may exist of various grades; almost the entire 
brain may be wanting, from the small remnants of which the cranial 
nerves originate. The hemispheres may be wanting, w4th the ex- 
ception of a small portion at the base. Conjointly with this, the 
cranial bones are defective, or of a rudimentary formation, and the me- 
ninges primarily distended into a bladder containing water, but which, 
having burst very early, hangs in atrophic folds over the shapeless 
cerebral masses. Again, only a small portion of the brain may be 
wanting — the anterior lobes, for example, and olfactory bulbs, the 
optic thalami and optic nerves, jDons Varolii, etc. Along with this, a 
corresponding malformation of that part of the face destined for the 
reception of these absent structures exists. The cranial bones in these 
cases, though small, may yet exist. The most striking of all defects 
in the longitudinal diameter is the single cerebrum, combined with 
cyclopia, and absence or deformity of the face. Next is a coalescence 
of the optici thalami and corpora striata ; or still again, an absence 
of the commissures, thus splitting the brain by this condition of 
the parts. In these cases the formation of the bony case may have 
taken place normally ; but idiocy and bodily defects always exist. 
Again, the brain, though existing, may be very small, but in all 
other respects perfectly formed; microcephalia. This condition oc- 
curs independently of that in which partial absence of some part 
exists. The vertex in these cases is low, the forehead flat, and the 
entire head pointed. Children so affected are capable of life and 
development, and, singularly enough, are not tardy in their mental 
development. 

Excessive growth of the brain is extremely rare, and the nu- 
merous splittings of the lobes which here and there occur are to be 
looked upon rather as anomalies of form than excessive formations. 

B.— DISEASES OF TEE SPIXAL COBB AND MEMBRANES. 

(1.) SpixalMexixgitis axd Myelitis. — The diseases of the spinal 
marrow are still in a state of obscurity, and all that is positively known 
of them could be stated in a few lines, if we were only to confine our- 
selves to the distinctly demonstrative anatomo-pathological alterations. 
First of all, as regards the much-abused hypersemia ; all post-m,ortem 
appearances must be excluded as spurious where the cadaver was 
not placed upon its face immediately after death, and the autopsy 
was performed later than twenty-four hours after life terminated. 
^Yithout this precaution there will be found in every case, even in the 



DISEASES OF THE NERVOUS SYSTEM. 377 

most normal, extensive post-mortem hypostasis, imbibition of the 
coloring matter of the blood, and putrid softening, by which it becomes 
totally impossible to establish the previous existence of any actual 
disease in the medulla spinalis. Although the anatomo-pathological 
condition is different in kind, still inflammation of the spinal cord and 
its membranes may be comprised in one group of symptoms, for the 
phenomena in both processes are almost identical, and hence a differ- 
ential diagnosis becomes extremely problematical. 

Pathological Anatomy. — The sac that is formed by the dura matei 
does not completely fill out the canal of the spinal column, but is 
secured there by adipose tissue, which accumulates more toward the 
vertebral laminae, anteriorly against the vertebral bodies by loose cel- 
lular tissue, and all around by venous plexuses. This sac of the dura 
mater, on its inner side, is firmly united with the external lamella of 
the arachnoid ; while the internal lamella of the latter hangs loosely, 
together with the pia mater. Between these external and internal 
plates or lamellse, is contained the cerebro-spinal fluid, which mingles 
^vith that of the meninges and ventricles of the brain, and even in 
small children may amount to a drachm. The pia mater of the cord is 
richer in vessels than that of the brain, and in the new-born child can 
readily be pulled ofi*. Having thus briefly recapitulated the normal 
condition of the sj^inal meninges, we may proceed to the investigation 
of the character of the hypersemia and of the haemorrhage. In young 
children the cerebral arachnoid and pia mater, and the veins within the 
spinal canal, are always plethoric ; in fact, the vessels are so full that, 
even when the precaution is taken of turning the body on its face im- 
mediately after death, extravasations are not of unfrequent occurrence. 
These pathological phenomena were first explained by Weber ^ of Kiel. 
It is not always easy to determine whether the blood found external 
to the dura mater was extravasated during life, or whether the blood 
was poured out upon tho dura mater, from veins that have been sev- 
ered during the removal of the vertebral laminee. The best means of 
guarding against an error is not to attempt the removal of very long 
sections of the vertebral laminae at one time, but to remove small 
portions, at different places, and then allow a feeble stream of water 
to play upon the exposed dura mater. The blood exuded from the 
veins after death is entirely washed away in this manner, while that 
extravasated during life is always somewhat coagulated, and adheres 
rather firmly to the dura mater. These haemorrhages are most fre- 
quently found in the cervical and lumbar regions, sometimes extend- 
ing but a short distance, or lining the whole spinal canal, forming a 
complete sheath of coagulated blood. Small extravasations are some- 
times seen more distinctly upon the disarticulated vertebral laminre 



378 DISEASES OF CHILDREX. 

than upon the dura mater, and for that reason the inner surface of 
the former must always be thoroughly exammed. The same kind of 
haemorrhages which occur externally to the dura mater are also met 
with in the sac between the dura mater and arachnoid, or the latter 
and pia mater. Here also the amount of the extravasations varies 
between a pin's head and such a quantity that the whole cord is sur- 
rounded by blood. It is less easy here for one to fall into an error, in 
sujDposing that this fluid has originated during the autopsy, because 
the dura mater has no large veins which might have been severed. 
Aside from these haemorrhages which, conjointly with the consider- 
ation of inflammation, have been disposed of, as the highest grade of 
hyperaemia, true exudations also occur upon and beneath the meninges. 
In the loose cellular tissue between the dura mater and the bony spinal 
canal some serum is always found, even in the normal condition ; it 
may, however, become considerably augmented, and, like a gelatinous 
mass, cover large regions of dura mater as well as remain adherent to 
the inner surface of the disarticulated laminae. In older children, 
after injuries to the spine, or in sj^ondylitis, a visible opacity and 
thickening of this membrane are also found, along with a deposit of a 
plastic fibrinous character. In all children a moderate quantity of 
spinal fluid is found on opening into the dura mater, wliich normally is 
of a pale-yellow color and perfectly clear, but which, in afi'ections of 
the arachnoid and pia mater, becomes opaque, flocculent, and bloody. 
Bloody discolored spinal fluid is especially found in children dying 
from pygemia during the prevalence of an epidemic of puerperal fever. 
The fluid exudations are always found in the most dependent part, 
according to the position of the body. In rare instances, a fibrinous 
deposit is found upon the dura mater conjointly with the flocculent 
cerebro-spinal fluid, which, like the purulent meningitis within the 
cranium, may become of a purulent natiu-e. Usually the spinal cord 
itself, in these morbid alterations of its membranes, is softened and 
eroded, so that it is difficult, in examining the spinal cord of a child, to 
diagnosticate a softening or sclerosis merely by the resistance which 
a scalpel meets, for the spinal cord, in general, is so soft that the 
slightest force will di\dde it. A^Tiere these morbid changes have taken 
place, there, as a rale, red softening is observed in some part of the 
cord itself. The most striking lesions of the cord are found in 
Pott's disease, where an angular cur\dng of the cord has taken place 
in consequence of a similar curving of the spinal column from destruc- 
tion of the bodies of the vertebrae. The cord at the angular spot is 
dense, flattened, and somewhat yellow, or more reddish-colored than 
elsewhere ; sometimes complete solution of continuity is observed. 
Symptoms. — In the new-born child, haemorrhages and inflamma- 



DISEASES OF THE NERVOUS SYSTEM. 379 

tions Tnthin tlie spinal canal furnish no characteristic symptoms, for 
the tonic and clonic spasms then observed occur even more frequently 
■without any demonstrable lesions of the spinal cord. The symptoms 
belonging to these conditions can be studied to better advantage in 
children with spina bifida, the sac of which is ruptured, or in a gan- 
grenous condition. Such children are attacked by intermittent spasms 
of the dorsal muscles, which may be transient, and only of slight de- 
gree. Sometimes, however, they take the form of the most violent 
and protracted opisthotonos. Toucliing the spinal column in these 
patients always causes excessive pain, and induces new spasms, and, 
for this reason, it is well to keep them constantly upon the side. Severe 
pains are also produced by touching either of the lower extremities 
before they become paralyzed. Motion aggravates the pain exces- 
sively, and induces new spasms. Finally, paralysis of the lower and 
then of the upper extremities supervenes, occasionally alternating with 
spasmodic con\Tilsions, and death ensues, after a few days, from tris- 
mus and tetanus. In older children, well-pronounced spinal symptoms 
are distinctly seen in caries of the spinal column, and as sequelae of 
scarlet and typhus fever, where complete paralysis of the lower ex- 
tremities remains. The patients describe very distinctly a sensation 
as if the limbs were covered with fur, or of ants creeping upon them ; 
the sensibility of the integument is diminished ; severe pain, however, 
is complained of, if much force be applied. Sometimes convulsive 
t^vitchings take place, soon followed by total paralysis. The process 
at first runs a febrile course, i. e., with a frequent pulse, hot skin, noticed 
most markedly on the back. This fever soon subsides, but the paraly- 
sis continues for many months, and perhaps during life. The rarer 
phenomena noticed in this malady are : disturbances of the sensibility 
of the skin, difficult deglutition, palpitation of the heart, attacks of 
dyspnoea, singultus, priapism, etc. In this connection, the paralysis 
and convulsions are briefly considered, because the symptoms are often 
found to exist without any demonstrable lesion of the spinal cord, and 
their practical importance will be considered farther on in a special 
section. Inflammation of the spinal cord occurs almost always in a 
sporadic form ; still, according to West, it has been observed as an 
epidemic in France, between the years 1842 and 1844, and lately in 
the hospitals and workshops of Ireland. Although very decided 
quantities of serous eff"usions were found between the meninges, still 
the cord was rarely and but very little altered. The disease ran a 
very acute course, and terminated fatally in from one to four days. 
In regard to the differential diagnosis between inflammation of the 
spinal cord and that of the membranes, a rule has been established 
that the first runs a chronic course, without any febrile movement. 



380 DISEASES OF CHILDREN. 

and ^vith a predominating paralysis, while tlie latter begins with active 
symptoms ; fever and general convulsions and paralysis subsequently 
become superadded. As has already been observed, both diseases, 
more or less developed, run their course together, and it is therefore 
impossible, and, in fact, useless, to seek for differential signs. 

Therapeutics. — An antiphlogistic, methodical treatment can be 
applicable in the rarest instances only, for the reason that the patients 
are too young, or, if advanced in years, have been so reduced by the 
preceding affections which are the fruitful cause of disease of the cord, 
such as spondylarthrocace, and scarlet or typhus fevers, that they do not 
tolerate an antiphlogistic treatment. In the early stage of the dis- 
ease, fever and convulsions are best treated by small doses of calomel. 
An infusion of arnica-leaves may be given when the first violent 
symptoms have been palliated, but it is not possible to say that any 
beneficial effect will be derived from it. The paralysis that usually 
remains offers no very unfavorable prognosis, for, with the increase of 
bodily strength, improvement, if not complete recovery, may take 
place. Cold douches to the back, and the administration of strych- 
nine, are important adjuvants; with the last remedy, however, we 
must never exceed one-eighth, or, at the most, one-sixth of a grain pro 
die, as otherwise symptoms of sudden poisoning are apt to be in- 
duced. The bladder should be constantly looked after, and the cathe- 
ter used, if its contents are not voided for more than twelve hours. 

(2.) Spina Bifida. Htdeoeehachia. [Hiatus Spinalis Cong en- 
itus.) — By hydrorrhachitis is understood a congenital tumor on the 
vertebral column, generally situated in the sacral portion, and pro- 
duced by a protrusion of the meninges of the cord through a bony 
aperture in the spinal canal. 

Pathological Anatomy. — Several degrees of this deformity may 
exist, and are known as follows : The defect may be confined to a por- 
tion, or include the whole canal. A total splitting of the vertebral 
column is only met with in monsters, hemicephalia, etc., and there- 
fore does not come within the domain of clinical investigation; but 
defective formation of individual vertebrae does not produce a condition 
incompatible with life, and must be more carefully studied. Here 
also we have marked gradations in the extent of the malformation. 
In the mildest grade of the disease the laminse are imperfectly devel- 
oped, or, being normal, the spinous processes are not united, and ex- 
hibit a narrow fissure between them. Again, the spinous processes 
may be entirely absent, or the bodies of the vertebrae are separated, 
and a wide fissure is seen to extend through the entire thickness of 
the spinal column. Lastly, in the extreme cases, the fissures are still 
loider, and several of the vertebras are in a rudimentary state. If the 



DISEASES OF THE NERVOUS SYSTEM. 381 

tumor itself be examined, the sac will be found to be continuous with 
the dura mater and arachnoid membranes of the cord ; the integument 
covering the tumor is of a normal character, or atrophic, and semi- 
transjDarent, or it may be absent. In the latter case doubtless it was 
ruptured in utero^ or during labor, and is found hanging in loose folds 
about the fissure. Where the membranes have remained entire, the 
tumor, during life, is tolerably tense, and fluctuates, while in the 
cadaver it is collapsed and flabby. Its contents are the liq. cerebro- 
spinalis. It varies in size from that of one scarcely perceptible to the 
touch, to that of a tumor the size of a hen's q^^ ; is usually situated in 
the lumbar region, but may extend throughout the entire column. 
The cord itself may be normal, or, if the tumor be situated low down 
in the lumbar region, it may be spread out tuft-like upon the inner 
wall of the sac. 

Symptoms. — These have been pretty well considered objectively. 
In shape, the tumor is oval or pyriform, sometimes pediculated ; the 
integumentary covering is discolored and red ; distinct radiating cica- 
trices are often observed on the flattened tumor, probably due to la- 
ceration of the sac, and subsequent union during foetal life. By press- 
ure, the tumor becomes somewhat smaller ; if a second sac exists, or 
when it is complicated with a congenital external hydrocephalus, the 
latter will become more tense. Pressure upon the tumor is extremely 
painful, and often produces tetanic spasms. In large tumors with atro- 
phic coverings, movements synchronous with the respirations may also 
be distinguished, the tumor increasing during inspiration, and diminish- 
ing during expiration. On examining the margins of the tumor, the 
fissure in the vertebrae, with its upper and lower angle, and leaf-like 
dilatation at the centre, will readily be detected. The subjects are 
mostly born alive, but very rarely live longer than a few days. The 
tumor often bursts during delivery, sometimes becomes gangrenous 
without rupturing ; the integument rarely retains a normal character, 
and subsequently becomes thickened. When air enters the tumor, or 
when the latter becomes gangrenous and bursts, purulent meningitis 
is apt to supervene, and will quickly terminate fatally. If a small 
tumor exists, and the integument remains intact, the patients may- 
thrive ; but paralysis of the bladder, rectum, and of the lower extremi- 
ties, is apt to ensue, and result in death. Yet, cases are reported of 
individuals, thus afi'ected, enjoying comparatively good health for 
twenty or thirty years. In the higher grades, the disease rarely exists 
by itself, but is complicated with congenital hydrocephalus, ectopia of 
the bladder, of the heart, club-feet, etc. 

Chaussier has shown, by the statistics of the Maternite, at Paris, 
that one case of spina bifida occurs in one thousand births. 



382 DISEASES OF CHILDREN. 

These tumors are not easily confounded with any other variety of 
tumor, as the vertebral laminae may be felt to be ununited in every 
true case of spina bifida. Rare instances of congenital hernia dor- 
sahs, cysts, adipose and honey-like tumors (Honiggeschwiilsten), are 
reported as curiosities in medical literature, as having been met with 
upon the spinal column, and calculated to mislead one into regarding 
them as cases of hydrorrhachis. The extraordinarily rare condition of 
intrafoetatio, a foetus within a foetus, where a large formless tumor with 
a few bones is found situated upon the sacrum, has naturally no anal- 
ogy whatever to the condition under consideration. 

Therapeutics. — Surgeons have tried countless varieties of methods 
with the hope of bringing about a diminution of the tumor, and clos- 
ure of the spinal canal. The almost invariable failure of all surgical 
procedures is due to the fact that the inner wall of the sac is formed 
by the spinal arachnoid membrane, and that any injury of this mem- 
brane is apt to produce meningitis, which cannot be limited to the 
sac. The tumor has been repeatedly punctured with exploring tro- 
cars and pierced with needles after forming vahadar openings in the 
integument. Lately Gaupp presented a boy seven years old, who 
had a hydrorrhacliis the size of a child's head, which he had cured in the 
first few weeks of infantile life by puncturing it eight times. After the 
first puncture, the fissure of the vertebrae could be distinctly felt, but 
the gap rapidly diminished, and finally closure took place in ten 
weeks. All the parts constituting the vertebrae are now present in 
this boy, but the spinous processes are somewhat flattened. Excision, 
with the subsequent use of compression by quills or small wooden rods, 
has been tried. Chassaignac treated these cases by puncture and 
injecting iodine, as in a hydrocele, and the pediculated variety has 
been tied ofi". Finally, constant, steady pressure upon the tumor by a 
hair pillow has been tried, but, although this method caused great pain 
and convulsive twitchings, it did not effect a single cure. All experi- 
menters have been obliged to acknowledge that their efforts have 
failed, nay, still more, that meningitic symptoms, which are always 
followed by death, came on immediately after the operation. Though 
the prognosis of hydrorrhachis is at best very unfavorable, most chil- 
dren dying even without operation, still, owing to the rarity of this 
condition, statistics upon this point are scarce, and it is therefore dij0&- 
cult to determine which of the two courses it is best to pursue. 

The most rational treatment, it seems to me, is to protect the sac 
from all kinds of injury and pressure, by a soft, cup-shaped pad 
which will only rest upon its margin, and which is secured to the 
body by elastic straps. If the hydrorrhachis is complicated mth con- 
genital hydrocephalus, as is frequently the case, then no other means 



DISEASES OF THE NERVOUS SYSTEM. 383 

should be adopted than that just described, for every diminution and 
compression of the tumor causes tension within the head. 

Q.—DISTUBBANCES IN THE NEBVOUS FUNCTIONS. 

A number of functional diseases of the nervous system are prob- 
ably only symptomatic of morbid alterations of the brain and spinal 
cord, if we may judge from the analogy between their individual 
phenomena and those of diseases whose pathological alterations are 
known. Tlie corresponding morphological or chemical alterations of 
the nervous centres, however, have not yet been demonstrated, 
which is attended with great difficulty on account of the circum- 
stance that most of these nervous diseases terminate favorably, and 
post-mortem e^ddence, therefore, is rarely attainable. As the demon- 
stration of the cerebral morbid processes has not yet been accom- 
plished, we have no other resource but to assume that the brain and 
spinal cord are in a normal condition, and to delineate symptomatically 
the individual phenomena, w^th their acquired denominations. 

(1.) Eclampsia Infantum (Convulsions). — Convulsions in chil- 
dren have long been w^ell known, even to the laity, and form an im- 
portant class in the diseases of children. They are known by many 
names: tremor of the head, silent tremor, silent wail, shudderings, 
spasms, and cramps. These all refer to the same disease, and are 
characterized by general or partial clonic twitchings of the muscles, 
and generally caused by some other febrile disease. Consciousness is 
almost or wholly gone, particularly when the convulsions are general. 
The single attack cannot be distinguished from an epileptic attack, 
but -epilepsy is characterized by its chronic course and unexpected 
recurrence, and freedom from fever. From chorea, eclampsia is dis- 
tinguished by the fact that the muscular contractions in the former 
continue incessantly throughout the day, and even for several 
weeks before the affection is relieved, and that the general condition 
is not affected by it. As regards the period of life at which convul- 
sions most frequently occur, childhood, up to the completion of the 
first dentition, is the most common ; still, even older children, who at 
an earlier age have suffered from eclampsia, are attacked with violent 
convulsions at the commencement of an acute attack of an exan- 
thema, even of an angina, or from an overloaded stomach. The 
milder, partial tremors in most instances last for several days, and 
reoccur frequently, especially in young children, in consequence of dis- 
turbed digestion. The general convulsion, to which alone the term 
eclampsia ought to be restricted, is not a protracted affection, it being 
either terminated in a single attack, or, after several paroxysms, 
always at certain intervals. 



384 DISEASES OF CHILDREN. 

The following symptoms are those generally seen in children 
under one year, who are attacked by the milder form : The child 
sleeps with half-closed eyelids, the ball of the eye is turned upward, 
and nothing but the white sclerotica can be seen through the palpebral 
fissure. The muscles of the face, during sleep, are contracted in vari- 
ous manners, whereby it may seem as if the child were smihng (risus 
sardonicus), or, as some astute nurses say, "The child is plajnng with 
the angels." The breathing is rapid and irregular, sometimes super-- 
ficial, and sometimes again accompanied by deep sighs ; the limbs 
tremble and twitch, the hands are clinched, and the lower extremi- 
ties, with the toes sprawling, are contracted against the body. From 
a restless sleep of this kind, the little one now awakes, frightened, 
with a cry, and manifests its discomfort by kicking, curving and 
twisting of the whole body. After expelling some intestinal gas, 
often with stools of green mucus, and very offensive, and sometimes 
vomiting, rest and general perspiration, as a rule, ensue, but often 
restlessness remains for some time. This condition may last many 
days, and recur several times a day at short intervals. Most of the 
children become feverish, and, owing to defective nutrition and con- 
stant muscular action, the face becomes emaciated and pointed. The 
more serious form, the true eclampsia infantum, manifests itself as 
follows : Generally the severer symptoms do not come on at the very 
beginning with the greatest intensity, but are usually preceded by 
the class of symptoms already detailed, which also vary according to 
the age of the child. Obedient, good-natured children become ^vil- 
ful, morose, choleric, are apt to be attacked by muscular twitching 
during sleep, gnash their teeth, and wake up frightened, with an 
anxious cry. The eyeballs are rolled upward, the lids are not com- 
pletely closed, the angles of the mouth are contracted into an unpleas- 
ant risus sardonicus, and the general state of the system is always 
somewhat perturbed. The patients are suddenly attacked by the 
paroxj^sm, both when asleep and when awake, and it is impossible to 
distinguish it from an epileptic fit. 

They suddenly become completely unconscious ; squinting or an 
unsteady rolling of the eyeballs sometimes comes on, butusually the 
eyes are fixed and staring. The facial muscles are attacked by the 
most varying tmtchings ; sometimes a smile plays over the face, 
and sometimes again an expression of anger or displeasure, which, 
conjointly with the exposed teeth, gives the patients an appear- 
ance of beastly ferocitj^ The jaws perform various acts, such as 
masticating, snapping, etc., accompanied by gnashing of the teeth. 
Fluids poured into the mouth excite very imperfect acts of degluti- 
tion, and the greater part flows out again. By this time the convul- 



DISEASES OF THE NERYOUS SYSTEM. 385 

sions have involved almost all the muscles of the body. The muscles 
of the back are in a state of tonic contraction, or are affected with te- 
tanic twitchings ; the extremities perform the acts of striking, thrust- 
ing, or twisting ; the respiration becomes very irregular, and, in con- 
sequence of spasm of the glottis, may stop altogether. After a few 
whisthng inspu-ations, the breathing is suddenly suspended, and death 
may ensue in a few minutes, if the spasm does not subside. As an 
effect of the impeded respiration, we may have bleeding from the mu- 
cous membrane of the mouth and nose ; but the bloody froth that is 
usually seen between the lips is oftener due to injuries of the tongue 
or mucous meml^rane, which frequently occur during the snapping, 
biting movements of the jaws, or may be produced by the numerous 
attempts of the relatives to prevent them. The heart contracts very 
rapidly, but not unrhythmically. The stools and urine frequently pass 
off involuntarily. The temperature of the skin on the body is nor- 
mal, on the extremities is apt to be diminished, and, toward the end 
of the attack, a perspiration usually breaks out. The sensibility of 
the skin is so completely abolished that the patients cannot be roused 
to consciousness by any means, not even the most painful irritants, 
and they often hurt themselves during their convulsive movements. 

The entire train of symptoms here presented is hardly ever ob- 
served in one attack ; some of them may be absent, without making 
the paroxysm a mild or an incomplete one. 

Such an eclamptic fit lasts for only a few seconds, or, at the most, 
minutes ; paroxysms that last longer than this are due to serious or- 
ganic lesions of the brain, and should be distinguished from eclampsia. 
A similar condition ensues after the termination of the convulsions as 
after an epileptic fit. The patients are semi-comatose and exhausted, 
the fever increases, the eyes become injected, cerebral symptoms su- 
pervene, the appetite is gone, and nurslings will not even take the 
breast. 

Formerly, when the antiphlogistic treatment was much more liber- 
ally employed in children, a distinction between eclampsia cum hyper- 
semia and cum anaemia was made, and the therapeutic measures were 
accordingly distinct. In the former, phlebotomy and subsequently 
leeches were used ; in the latter, these remedies were not employed. 
Now, when abstractions of blood are not so much in favor, this dis- 
tinction is of less value ; in fact, we have learned that pale, anaemic 
children are as liable to be attacked by convulsions as robust and 
plethoric ones. 

Theoretically we distinguish, in addition, (1), an idiopathic, i. e., 
an eclampsia issuing directly from the brain ; and (2), a dexiteropatlnc, 
i. e., one reflected to the brain from a diseased organ. Practically, this 
25 



386 DISEASES OF CHILDREX. 

distinction is often impossible, and Tve remain uncertain, even after a 
long observation of the case, which kind of eclampsia we have to deal 
with. The autopsy alone can clear up this obscurity. 

Etiology. — (1.) Idiopathic edampsia may be produced by me- 
chanical compression of the head during delivery, by pathologi- 
cally demonstrable alterations in the brain, particularly tuberculosis, 
or by nutriments and medicines, as spirituous liquids and narcotics, act- 
ing directly upon the brain, and by insolation. Children with a soft 
occiput are more disposed to convulsions than others, a detailed 
description of which will follow in the article on rachitis ; they may, 
however, also originate from direct cerebral irritation, for example, 
from pressure from ^vithout. Mental over-exertion is also advanced 
as a cause, but it is certainly the rarest of all the causes. Violent 
fright, great anxiety, and vehement outbursts of anger, are perhaps 
the most jDrobable ones. 

(2.) Deuteropatliic or sympathetiG edampsia is by far the most 
frequent form, and the intestinal, canar the source from which reflex 
convulsions oftenest arise. The intense irritability of the primag vias in 
all ages of life furnishes the greatest opportunities for them. They 
may even be occasioned in the first few days after birth, b}^ the re- . 
tention of the meconium, but at this age there may always be a sus- 
picion of a mechanical injury to the head during the act of dehvery. 

There is also a peculiar, chemical, unexplained cause, namely, the 
milk of a wet-nurse, who, shortly before, had been subjected to some 
mental excitement. Instances have been reported of children, pre- 
viously perfectly healthy, having been attacked, soon after taking such 
milk, by short but \dolent convulsions, which terminated in sudden 
death ; and at the autopsy no cause whatever could be found. These 
cases, however, are so rare, in comparison with the many cases in 
which such mental excitement on the part of the wet-nurse is not fol- 
lowed by such results, that this supposed cause has been justly doubted. 
On the other hand, however, those evil effects, produced by an artificial 
nutrition, from which intestinal catarrh follows, and in the train of 
which milder and more serious cerebral irritation must sooner or later 
ensue, cannot be doubted. These have been seen to occur with their 
greatest intensity at the period of weaning. Such children suffer 
first from flatulence and colic, afterward are attacked by a diarrhoea of 
green-colored and fetid stools, and vomiting ; they become very rest- 
less and feverish, and, finally, convulsions ensue. In other cases the 
latter are not preceded by diarrhoea, but, on the contrary, by consti- 
pation and loss of appetite. In older children, indigestion and the 
irritation produced by worms merit particular consideration. 

An additional cause, and one that deserves to be well attended to. 



DISEASES OF THE NERVOUS SYSTEM. 387 

is found in tlie eruption of the teeth. This process is generally com- 
plicated with digestive disturbances, and hence these may be regarded 
as the prime cause o£ the convulsions. But there occur cases in which 
the digestion is entirely undisturbed, and the reflex convulsions there- 
fore have to be explained by other causes than the inflammation of 
the mucous membrane alone. To authorize the opinion that dentition 
is the cause in any case, the child must be in one of the five periods 
of dentition. The mouth will then be reddened and hot, the mucus 
is often secreted in less quantities than in the normal state, one or the 
other cheek is dark red in color, it is very restless, and bites at 
every thing that comes near the mouth, even the nipple of the wet- 
nurse. Eclampsia, originating from dental irritation, belongs to the 
serious forms, and often leaves behind it partial paralysis and im- 
becility. 

A third principal cause of convulsions is the hreaking out of an 
acute febrile disease, particularly an acute exanthema, where the convul- 
sions in children seem to be analogous to the chill of fever in adults. 
These eclampsias are attended by very little danger, are of short dura- 
tion, and rarely followed by pernicious consequences. This cause 
may be conjectured with tolerable certainty when eruptive diseases, 
which the child has not yet experienced, happen to prevail epidemic- 
ally, and the prodromata of such an exanthema have manifested them- 
selves. If it be measles, there will be cough, sneezing, and lachryma- 
tion. If scarlatina, there will be angina, with difficult deglutition. If 
small-pox, persistent headache, pain in the back, and violent fever. 
Often, however, no prodromata at all are observed, and only the course 
of the disease explains the cause of the convulsions. Among the 
acute diseases to be mentioned, besides the acute exanthemata, are 
pneumonia, intermittent fever, and fever following injuries and opera- 
tions and simple anginae. A male child was once placed under my 
care who sufi'ered two or three times every year from intense angina, 
and in the first day of the illness an eclamptic fit invariably took 
place which was not distinguishable from epilepsy. I finally extirpated 
both tonsils, and the eclampsia, or, as the afflicted parents supposed, 
the epilepsy, has not recurred during the last two years. 

■ Finally, cases are also reported, especially by the older -^vriters, of 
convulsions said to have originated after the rapid healing oi i^ro fusel ij- 
discharging eruptions. Some remarks have already been made, when 
on the treatment of acute hydrocephalus, concerning the connection be- 
tween the latter and humid eruptions of the head, and it cannot be de- 
nied that, in the rapid healing of external suppurations, the internal 
organs, and consequently the brain, are subject to the danger of becoming 
inflamed. On the other hand, we must also acknowledge the fact that 



388 DISEASES OF CHILDIIE]^'. 

many hundreds of cases of impetigo disappear rapidly, either spontane- 
ously or by treatment, yet the children remain as well as before. 

The inheritaMlity plays a certain role in the etiology of this dis- 
ease. The parents, as a rule, have suffered from this affection, and the 
mothers, in particular, are hysterical and rejDeatedly afflicted with hy- 
pergesthesia. JBouchut relates the history of a family of ten persons, 
all of whom suffered in their youth from convulsions. One girl of this 
family married, gave birth to ten children, and nine of these suffered 
from eclampsia. 

Course, Termination, and Progress. — Partial muscular contractions, 
the so-called convulsions (Fraisen), may be protracted for many days 
during an acute affection, without very greatly augmenting its danger. 
The genuine eclampsi^e, however, are mostly completed with a single 
attack, and the very first eclamptic fit may terminate fatally, or the 
morbid process that caused it may become fully developed on the 
following day, thus removing the cause for sympathetic convulsions. 
Those induced by gastric irritation are relieved by vomiting, expulsion 
of flatulence, or diarrhoeal stools ; those depending upon toxsemic 
causes never return after the acute exanthema, scarlatina, roseola, or 
variola has once broken out. 

As has been observed on a former occasion, this kind of con\Til- 
sions is seldom fatal ; nevertheless, it always gives reason for the 
conjecture that the disease following will be strongly developed and 
run its course with violent sjmaptoms. In general, the rule may hold 
good. The younger the child the more critical will be the prognosis. 

According to my experience, those convulsions due to dentition 
and complicated with intestinal affections — excepting those, in fact, de- 
pending upon actual^ cerebral disease, which almost always lead to 
death — offer the worst prognosis. Such children die either in a fit or 
are attacked by hydrocephaloid disease and perish. Others live inva- 
lids from permanent brain-injury resulting from the convulsive disease. 
Almost all squinting children, in whom the strabismus cannot be re- 
ferred directly to a visible defect of the cornea and lens, have suffered 
from eclampsia in the first years of life. In addition, loss of either one 
or more of the senses, amaurosis or deafness, imbecility in various de- 
grees, chronic hydrocephalus, and general or partial muscular paralysis, 
may result from this distressing malady. 

Therapeutics. — We must first discriminate between the partial 
musciilar twitchings (the Fraisen) and the general epileptiform con- 
vulsions, the true eclampsia infantum. The treatment, moreover, varies 
according to the age and strength of the child, and it is absolutely 
necessary to institute a thorough examination in order to get ujDon the 
right track as to the cause of the disease. In this examination the 



DISEASES OF THE NERVOUS SYSTEM. 389 

physician must not content Mmself mth the assertions of the relatives, 
but should personally examine the entire body of the child. For, a 
sphnter in the sole of the foot, between the toes, a foreign body in the 
nostrils, or in the external ear, may also be the exciting cause, the 
removal of which will rapidly cure the disease. 

In the paroxysm itself the physician can very seldom render any 
material aid, for the reason that by the time he reaches the house the 
convulsions have almost invariably passed off, and he has to confine 
his services to imparting comprehensive instructions with the view of 
preventing the recurrence of the attacks. The first thing to be done 
is always to undress the child as quickly as possible, so that no con- 
stricting bands or skirts may additionally impede the respiration and 
circulation. Next the child, with the head slightly elevated, is laid 
upon a large bed, or on the floor, when the convulsions are so violent 
that there is danger of injury to the extremities against the sides of 
the bed or of its falling off. That such children are not to be left alone 
is self-evident. By sprinkling the face and exposed chest with cold 
water we may succeed in inducing deep, spasmodic inspirations, by 
which the danger of suffocation at least is lessened. No other striking 
abortive effect, however, is usually accomplished by this procedure. 

Venesection, suggested by some therapeutists in this disease, is, 
aside from all other objections, inadmissible, for the reason that it is 
not possible to perform it during the paroxysm, or at least not without 
uncertainty and danger, for, when a vein has finally been opened, the 
aperture is immediately closed again by the contraction of the arms 
and displacement of the wound in the cutis, and the flow of blood 
must necessarily be arrested. I may mention here the suggestion 
thrown out by Grantham^ to constrict the skull in children whose 
fontanels are not yet ossified, by firmly bandaging it. I have tried 
this bandaging of the scalp in two cases, but have derived no benefit 
in either; on the contrary, such an amount of restlessness was pro- 
duced, when continued for the long time recommended by the aforesaid 
author, as a prophylactic, that after a few days it had to be abandoned 
altogether. 

As regards the benefit to be derived from remedies after the at- 
tacks have passed, we have to look for that mainly in derivatives. 
Sinapisms, or, in infants, leaven is applied to the calves of the legs, or 
these parts are rubbed with mustard spiritus, by which intense redness 
is almost instantaneously produced. When there is the least sus- 
picion of the existence of gastric irritation, a derivative from the intes- 
tinal canal should also be administered. This should only be omitted 
in children who before and during the fits had had diarrhoea, and had 
expelled large quantities of flatus. To older children, who shortly be- 



390 DISEASES OF CHILDREN. 

fore the paroxysm had taken a considerable amount of nutriment, it is 
best to give a proper emetic of, for example, tart, stihiat. gr. i., dissolved 
in a strong infusion of ipecacuanha, by which the entire contents of the 
stomach are soon evacuated. But, where no probable overfeeding, or 
indigestion, can be ascertained to exist, calomel is to be preferred to the 
emetic ; half of or one grain of calomel is to be given to the child 
every hour, until a few evacuations have been produced. "When con- 
stipation is the presumable cause of the eclampsia, a clyster may be 
administered, even during the convulsions. I have never been com- 
pelled to resort to croton-oil in this affection. 

Of all the antispasmodics, oxide of zinc, in one to two grains pro 
die, is the most useful, and best adapted for a prolonged use. It is 
rather difficult to form an opinion as to the benefit derived from such 
prophylactics, for the reason that in most cases but one eclamptic fit 
occurs. Narcotics are not admissible in this disease, because they do 
not act quickly enough, when administered during the fit, to arrest it, 
and afterward are apt to induce cerebral congestion. 

An after-treatment, by the use of tonics, iron, quinine, and ale, may 
be indicated, chiefly after eclampsia9 consequent upon gastric and 
dental irritation. 

(2.) Paralysis. — Since central paralysis, produced by diseases of 
the brain and spinal cord, has already been mentioned in connection 
Avith those affections, we still have to speak of what has been called 
essential paralysis of one or more extremities, coexisting vrith perfect 
integrity of the nervous centres, and also of the peripheral paralysis 
of th.Q facial nerve. 

As regards facial paralysis., it is sometimes observed immediately 
after birth, but, on account of the immobility of the features, it is much 
more difficult to recognize in the new-born child than in the adult. The 
lesion does not become noticeable till the child begins to cry ; the 
angle of the mouth on the sound side is then seen to be drawn outward, 
and the whole healthy moiety of the face is generally thro'vvn into folds, 
while the paralyzed half remains as immovable as before. When the 
cause of the paralysis is central, the uvula will also be seen to stand 
obliquely ; in most instances, however, no alteration whatever can be 
observed on the palate and uvula, as the cause of the paralysis usually 
lies in the course of the facial nerve. The most frequent cause of the 
paralysis of the new-born child is to be found in the use of the forceps. 
In addition to this, it may also be due to a congenital smallness or dis- 
tortion of the petrous portion of the temporal bone, which occasionally 
occurs. Later in life, caries of this bone, glandular indurations, and 
contracting cicatrices in the vicinity of the facial nerve, are the most 
common causes. 



DISEASES OF THE NERVOUS SYSTEM. 39I 

The treatment of facial paralysis depends upon its cause, and is 
effectual only when that is capable of removal. Contracted cicatrices, 
most frequently the result of scrofulous ulcers, and glandular tumors, 
may be removed by an operation ; on the other hand, paralysis, the 
effects of caries of the petrous portion of the temporal bone, as a rule, 
is irremediable. 

Essential xjaraly sis of single extremities, very briefly alluded to in 
the older text-books, is a much more frequent and interesting affection, 
and has lately been more accurately described by Heine, Kennedy, and 
Rilliet. 

By essential paralysis is understood a partial or complete loss of 
power of motion, and of sensibility in one or more extremities, with- 
out any discoverable evidence of its depending upon lesions of the 
nervous centres. Tliat the central organs have experienced none, at 
least no material alteration, may be readily concluded from the facts 
that the paralysis sometimes disappears very quickly, after two or 
three days, and from the reports on autopsies of children with essen- 
tial paralysis who had succumbed to other acute affections. Milliet 
and Barthez have had two opportunities to dissect such bodies, and 
Fliess has had one. The former found no alteration whatever in the 
brain and spinal cord ; the latter, in a case of paralysis of one arm, 
found a simple congestion of the meninges of the cord on a level with 
the brachial plexus. Post-mortem examinations of essential paralysis 
are always very rare occurrences, because this disease per se is not 
apt to terminate fatally. 

Symptoms. — Paralysis, usually, in most instances, begins in this 
manner : The child, during dentition, but otherwise in good health, falls 
asleep at the usual time in the evening, is somewhat restless durijig 
the night, and, on the following morning, awakes with one arm or leg, 
seldom both legs, paralyzed. The palsy is complete on the very first 
day of its occurrence. In other instances, difficulties of dentition, with 
convulsions, or even eclamptic fits, precede it for several days. ^' The 
palsies which follow these phenomena are mostly hemiplegic or 
paraplegic, and are of longer duration than those which originate in a 
simple manner. In exceptional cases, essential paralysis of the lower 
extremities follows chorea, typhus fever, and the acute exanthemata. 
In these latter cases it develops itself most markedly during convales- 
cence. It is very questionable whether it is really always primarily 
peripheral, and originates without any morbid alterations of the me- 
ninges. That paralysis which affects one extremity, most frequently 
the upper, and which comes on suddenly during the night, and mth- 
out the least disturbance of the general system, presents the simplest 
form of essential paralysis under discussion, and to it we will now call 
attention. 



392 DISEASES OF CHILDREN. 

Although the whole group of symptoms must be regarded as com- 
plete from the very beginning of the disease, still, two stages may be 
distinguished in its course: (1), the stadium of simple paralysis; and 
(2), that of atrophy. 

The second stage, when the disease runs an acute course, and soon 
passes into recovery, does not take place at all ; it only occurs in cases 
that have lasted for some months. In the first stage, no alteration 
can be discovered in the length, circumference, or temperature of the 
afi'ected limb, but, when the malady is longer in duration, the limb be- 
gins to waste, the muscles become flabby and thin, the adipose tissues 
also decrease, and, lastly, even the longitudinal growth of the bone 
is more or less arrested. 

As regards the symptoms of the individual palsies, those of the 
arm manifest themselves in the following manner: The arm hangs 
powerless by the side. It is a remarkable fact that paralysis of the 
muscles of the arm occasionally occurs, without involving the muscles 
of the hand and fingers of the same limb. The reverse of this condi- 
tion has never, to my knowledge, been observed. In tliis case the 
patients are still able to grasp with the hand, but are unable to lift 
the grasped object. For example, they can grasp the spoon, but can- 
not carry it to the mouth. Older children try hard to use the affected 
limb, and assist it with the sound one. The only alteration of form 
that is noticeable from the very commencement is, a flattening of the 
outer contour of the shoulder, caused by a paralysis of the deltoid 
muscle, and the weight of the dependent arm itself. 

Essential paralysis of a lower extremity seldom implicates all the 
muscles of the limb ; it often affects only those of the leg, and not 
always all of these. The foot is inclined either inward or outward, 
according to the muscles affected. The disease is very easily recog- 
nized. In children not yet able to stand, the palsied limb lies quietly 
during their crying and struggling, while the other is drawn up against 
the body, and, when seated upon a chair, the paralyzed Hmb dangles 
about hfelessly. In children w^ho have walked, the signs are still more 
marked. They make no further attempts to walk, or, if it be a partial 
paralysis — that is, of only certain of the muscles — will drag the leg 
after them, or hop on one foot. 

When both lower extremities are affected, the child will lie mo- 
tionless in bed. It, however, soon learns to sit, aided, perhaps, by 
returning functional ability of the limbs, which progresses from above 
downw^ard, so that it is first able to move the thigh, next the leg, 
and finally the foot. 

The peculiarity of this peripheral paralysis is, that neither the 
bladder nor the rectum ever becomes affected by it. 



DISEASES OF THE NERVOUS SYSTEM. 393 

Its course and duration are variable. In most cases, tlie palsy dis- 
appears completely after a few weeks or montlis, without leaving any 
effects behind, but, when it lasts longer than six to eight weeks, with- 
out any improvement having taken place, the signs of commencing 
atrophy, so far as concerns the alterations of form, will ensue. A 
marked decrease in the temperature of the skin soon becomes super- 
added, followed by complete anaesthesia, and frequently, also, by slight 
oedema of the dorsum of the feet, the chief cause of which is, undoubt- 
edly, the feeble circiilation of the affected limb. 

The atrophy never proceeds so far as that it is not still possible, by 
faradization, to produce contractions of the single muscles. The sen- 
sibihty in the paralyzed limb is continued for a much longer time, but 
whether it is as perfect as in the sound limb is not easy to decide, for 
the children are mostly still too young to be able to make very fine 
discriminations. During the first few days after the invasion of the 
palsy, hyper^esthesia and decided painfulness are sometimes observed, 
seemingly due to inflammation of the neurolemmata ; still, they may 
also be suspected to be caused by preceding contusion, or they may be 
feigned. After several days, these pains disappear. 

The longer the palsy exists, the greater the alterations of form be- 
come. The shoulder-joint becomes enfeebled to such a degree that a 
dislocation of the upper arm may take place. A depression appears 
beneath the acromion process, and the deltoid muscles become com- 
pletely flattened. In partial paralysis of the lower extremities, con- 
tractions in the direction of the sound muscles occur, producing club- 
feet and genu valgum on the low^er extremities, and scoliosis of the 
spinal column, in consequence of obhquity of the pelvis. 

, In regard to the duration of this disease, Hilliet and JBarthez have 
furnished us with more accurate statements. In one case, a well- 
marked essential paralysis disappeared in twelve hours; in many 
others, in from six to eight days. Complete recovery has been seen to 
take place after a duration of eleven months. Even when the affected 
extremity exhibits imperfect development, and is able to perform but 
few and feeble movements, it is still possible, even after the lapse of 
years, by proper gymnastics, and by the use of electricity, to imj)rove 
its condition, and, perhaps, to cure the disability. 

Etiology. — Essential paralysis is a disease of early cliildhood, and 
is most decidedly connected with the eruption of the teeth. Children 
under half a year are but seldom affected with it ; most frequently 
it comes on at the eruption of the molar teeth, and becomes ex- 
tremely rare after the completion of dentition. No age of life, 
however, is exempt from it. More boys than girls, according to my 
experience, are afflicted with it. This, however, may also be ac- 



394 DISEASES OF CHILDREN. 

cidental, for, in the more recent text-books, this disproportion is not 
alluded to. 

The state of the constitution seems to possess no influence in this 
disease, for most of the children attacked by paralysis have enjoyed 
good health, and have flourished well up to the time of the attack. 
While scrofulous children are sometimes its victims, there is, neverthe- 
less, no conclusive evidence that the very common scrofulous cachexia 
furnishes any special predisposition to the disease. The only tolerably 
constant occurrence in it is congestion of the brain, and disposition to 
constipation during dentition. In some of the more recent works it 
is stated, with especial emphasis, that exposure to cold is the most 
frequent exciting cause ; but a single case, however, is cited, in sup- 
port of this statement, namely, that of a child which sat upon a cold 
stone, and thereupon contracted a paralysis of one of the lower ex- 
tremities. The many hundred other children, especially those belong- 
ing to the lower classes, who habitually sit upon cold stones, and yet 
escape the disease, furnish evidence which weakens this theory as to 
the exciting cause of the disease. 

Therapeutics. — The antiphlogistic treatment, local abstraction of 
blood, calomel, etc., has, as in almost all diseases, also been employed 
in this paralysis, but without better results than those obtained from 
the expectant treatment. The same may be said of purgatives, and, 
in fact, of all the other remedies recommended in its treatment. Many 
of these have been enthusiastically praised, because most essential par- 
alyses disappear after one or several weeks, whatever agents have been 
employed. But, as to a specific effect of the remedies recommended, it 
is futile to speak, for there are many cases of essential paralysis, as 
to the diagnosis of which there is no doubt whatever, and yet resist 
all methods of treatment, even that with electricity. 

The most rational and the simplest treatment for the first few 
weeks of the paralysis seems to be the daily employment of the cold 
douche, afterward wrapping up of the hmb warmly, passive motion, 
and spirituous frictions. Most essential paralyses are easily cured by 
these means. If, after four weeks, no improvement is effected, then it 
is time to obviate, by induced electricity, applied daily for ten minutes, 
the consecutive atrophy of the muscles. 

If, after several weeks more, no improvement is realized, the in- 
ternal use of sulphate of strychnia, -^ to \ gr. ^yo die, may be resorted 
to. This preparation is much preferable to nux vomica, on account of 
the variable quantity of strychnine the latter contains. The utmost 
caution should be employed in the use of this remedy ; the relatives 
should be informed of its toxic action, and precautionary measures 
should be adopted in case sudden \dolent tetanic attacks happen to 



DISEASES OF THE NERVOUS SYSTEM. 395 

come on. The best means for this pm^pose is to dash some cold y>'ater 
on the body, and to administer strong coffee. 

Deformed extremities must be restored to their normal shape by 
orthopaedic treatment, and, for the incurable paralysis, mechanical 
orthopgedia, with its numerous ingenious apparatus, may likewise be 
advantageously resorted to. 

(3.) Choeea Minoe. The Little or Ei^^glish St. Vitus's Dais^ce, 
MuscuLAE Jactitation^. Ijtvoluntaey Movements of the Muscles. 
Ballismus, Scelottebe. — The best description of the little St. Vitus's 
dance is given by ITasse, in his Diseases of the Nervous System, in 
Yirchoio's Pathology and Therapeutics, and which also forms the 
basis of the follo^ving characteristic description. 

By chorea ininor we understand a constant involuntary move- 
ment of almost all the voluntary muscles, Avhich increases in severity 
when the movements are being directed by the will, and ceases only 
with the total abolition of consciousness ; for example, in sleep. This 
deSnition sufficiently distinguishes St. Vitus's dance from the other con- 
ditions which w^ere formerly spoken of in connection with it, such as 
the great St. Vitus's dance, the dancing mania, the imitatory popular 
diseases, and the tarantula disease. 

Symptoms. — The constant involuntary jactitations are seen either 
in all the voluntary muscles of the body or in some portions only. 
They may be seen in the upper moiety of the body, or confined to one 
side ; in one arm, and the corresponding leg, giving rise to the 
dance-hke movements in those limbs. In very rare instances one arm 
and the opposite leg are affected by this muscular restlessness. Nor 
are all the extremities always imphcated in a uniform manner, for, 
while one arm is not at rest for a single moment, twitching inces- 
santly, the other may be at rest for several minutes, and, indeed, 
only be affected by slight, barely-perceptible muscular tremors. The 
same inequahty of the affection is also observed in the lower extremi- 
ties. The muscles of the face may possibly be wholly spared, while 
those of the lower extremities are in an incessant state of jactitation. 

Now, as regards the single twitchings, those on the upper ex- 
tremities, as a rule, are the most noticeable. The most peculiar distor- 
tions and tremors are observed in the arms ; the shoulders are drawn 
high upward, as if the patient were trying to scratch himself; the fin- 
gers are sometimes closed, and then again extended, or they are in- 
cessantly employed in pulling at the garments. The feet are not at 
rest for a single instant, and an incessant stamping is produced by the 
different involuntary contractions. Wlien the patient lies doAvn, the 
toes spread out, and contractions also take place at the Imee-joint. 
The gait becomes unsteady and uncertain, and, in extreme cases of the 



396 DISEASES OF CHILDREN. 

affection, walking becomes altogether impossible. When one limb is 
more severely affected than the other, it produces limping. The 
most singular movements take place about the head. It is twisted, 
shaken, sometimes spasmodically drawn to one side, and then again 
to the other. The contractions of the facial muscles produce the most 
wonderful contortions, which may even degenerate into the severest 
caricature-like grimaces. The eyes glare, or temporary strabismus 
comes on, and the eyelids usually blink incessantly. 

The muscles of mastication and deglutition also become affected 
by the restlessness, and during mastication the patients bite the 
tongue or mucous membrane of the cheek. Even gnashing of the 
teeth, when the mouth is empty, occurs. Deglutition is not always 
performed according to the will, nor are the movements of the tongue. 
Hence these children stutter, stop in a middle of a sentence, and often 
bite their tongue in the attempt to speak. The body is turned about 
and twisted in every direction. The respiratory muscles, however, do 
not noticeably participate in the jactitation, at least the inspirations 
are not executed irregularly. 

The immediate effect of this condition is of course a constant in- 
terference with the voluntary movements, which react and cause a 
visible aggravation of the convulsive affection. The patients are un- 
able to eat properly, are attacked by twitchings while in the act of 
carrying the food to the mouth, they bespatter themself with fluids, 
and prick themselves in the face, if imprudently a fork has been al- 
lowed them. While in the act of writing, they will suddenly make 
long hooks, and crooks in the letters, or thrust the pen so violently 
upward as to pierce through several pages of the copy-book. When 
they attempt to undress themselves, such violent tremors result, in con- 
sequence of the greater voluntary movements necessary for that 23ur- 
pose, that the clothes are torn. When they are commanded to stand 
quietly, the very effort to comply only renders the stamping still 
greater. If ordered to protrude the tongue, that organ will be rolled 
out of the mouth with the most peculiar shiftings and twistings, and 
can in no case be kept quietly protruded for any length of time. 

When an attempt is made to hold the affected part firmly, the 
restlessness becomes still more aggravated than when a voluntary 
movement is undertaken. A permanent aggravation of the whole 
affection may even be produced thereby. 

The sensibility of the skin is not diminished in chorea, and the 
ordinary reflex movements may be induced by the various cutaneous 
stimuli, such as pricking, burning, etc. Also sneezing and gaping 
are executed mthout any hinderance, nor does the disease seem to 
exercise the least influence upon the evacuation of the bowels or 



DISEASES OF THE NERVOUS SYSTEM. 397 

bladder. It is worthy of remark, and a curious fact, that these chil- 
dren, even in the severest cases, where they are the whole day 
through in a constant state of agitation, never complain of fatigue, 
the contractions being as severe in the evening ; often, indeed, they 
even become stronger. No constant signs of any disease in the 
nervous centres can be detected in this affection. Nor has the symp- 
tom advanced by Siehel, of pressure along the vertebral column almost 
always producing pain, been confirmed by other observers. 

The disposition of the mind in choreic patients often undergoes a 
change. They are much inclined to weep, and become choleric ; pre- 
viously well-disposed and kind children become petulant and malicious. 
If the disease is protracted for a long time, the memory will also become 
somewhat impaired. Numerous and noticeable as the symptoms are 
when the child is awake, in sleep they almost disappear. In the 
evening when the patients become tired and lie down, the jactitations 
gradually subside, and cease completely as soon as consciousness is 
gone. The sleep is usually less tranquil than in healthy children, and 
even some slight choreic movements are made during dreams, but, 
with the awaking, all the symptoms come on again with their former 
severity. 

Chorea is not attended by fever, and runs its course without any 
visible disturbances of the general system ; on the contrary, it has even 
been observed that the muscular tmtchings became markedly feebler 
during the course of an intercurrent acute affection, for instance, an 
acute exanthema, and, in that case, are quickly followed by a per- 
manent improvement, and a complete recovery. The pulse, in simple 
chorea, is neither irregular nor accelerated ; the contradictory state- 
ments of some authors are probably due to the difficulty of securing 
the radial artery, owing to the constant jerking of the tendons. But, 
if the heart is carefully auscultated, it will be conclusively seen that 
the rhythm and frequency of the cardiac contractions are always 
normal. 

When the disease lasts for some time, the nutrition will now and 
then suffer materially, the children become pale and lean, and, in older 
girls particularly, anemic cardiac murmurs and chlorotic symptoms 
generally manifest themselves. 

Its course is always chronic, and a tolerably well-developed chorea 
is scarcely ever cured in less than two or three months, others last 
half, and even a whole year ; indeed, Homherg relates the case of an 
old woman seventy-six years of age, who suffered from chorea seventy 
years, was still living, and would undoubtedly take it with her to 
her grave. 

Chorea has also been divided into stages, such as (1), the stadium 



398 DISEASES OF CHILDREN. 

of premonition; (2), of aggravation; (3), of the climax; and (4), of 
subsidence. But divisions into stages, in diseases wliere the transi- 
tions are so gradual, and are not ushered in hj any marked symptoms, 
have but little value. The invasion of the disease is gradual in all 
cases. The subjects noticeably become awkward, drop every thing, 
break almost every thing that is given them, often stumble, and be- 
come anxious and intimidated in consequence of the injuries which 
they suffer as the result. Generally, the first involuntary movements 
take place after some mental excitement, such as fright, fear, anger, 
etc. At first they are seen in some small groups of muscles, but sub- 
sequently, and more or less rapidly, become general, so that in two 
or three weeks the disease has attained its climax. From that time 
the symptoms remain stationary for at least four to six weeks, with- 
out undergoing any exacerbation or amelioration. Finally, an almost 
imperceptible improvement ensues. Relapses, however, are of frequent 
occurrence. jSee observed them thirty-seven times in one hundred 
and fifty-eight cases. In the end, however, a complete recovery gen- 
erally takes -plsLce. An exceptional case may sometimes occur, in 
which a twitching of individual groups of muscles, especially of 
the face, remains for years, or through life. JVicJce and Leudet also 
describe some fatal attacks. The disease, in those cases, rapidly as- 
sumed a form of the utmost gravity, coma came on, attended by the 
involuntary passage of the stools and urine, soon followed by collapse, 
irregular respirations, small pulse, and death. 

Etiology. — Chorea is almost exclusively a disease of childhood, 
and, when adults suffer from it, it will be found that they acquired it 
during their youth. Most frequently it attacks children between the 
sixth and sixteenth years, owing to which, its origin has sometimes 
been sought for in the second dentition, and then again in the pros- 
pective puberty. Although these processes may also furnish a dispo- 
sition to chorea, still their connection with it is not a very intimate 
one, for, it very frequently disappears without a molar tooth having 
been cut through, or menstruation having made its appearance. 

Chorea is one of the few diseases which attack the sexes in un- 
equal numbers. According to a compilation by Duffosse, seventy- 
nine out of two hundred and fifty patients were males, and one hun- 
dred and sixty-one females, and See maintains that the ratio of cases 
of the disease among boys, as compared with girls, is as one-third 
to two-thirds. Here, in Munich, this disproportion seems to be still 
greater, for, among eleven chorea patients which I noted in my diary, 
I find only one boy affected. 

No special inheritance exists here, and it happens only exception- 
ally that the child, of a mother affected during her youth with chorea. 



DISEASES OF THE NERVOUS SYSTEM. 399 

is attacked by it. On the other hand, however, the fact is not to be 
ignored, that most of the mothers of such children have an irritable 
nervous disposition, and suffer from the most varying forms of hys- 
teria. Preceding febrile diseases likewise predispose one to chorea. 

No distinct influence of the season of the year can be perceived in 
this country, while chorea very seldom occurs in the tropics ; in the 
northern latitudes, on the contrary, it is said to be more frequent. 
Whether it may also be epidemic, as is claimed by some of the 
investigators of medical history, is still not satisfactorily established. 
Those so-called epidemics are probably referable to simple imitation. 
That chorea may originate in girls' boarding-schools, as the result of 
mimicry, is vouched for by many reliable observers, and instances of 
that nature have recently occurred in a Tyrolean village, and in a 
pensionnat at Eisenach. 

We find an analogy for this circumstance in the origin of hysteric 
spasms, by merely seeing a person suffering from such convulsions, as 
is often observed in the female sections of large hospitals. 

Fright, in particular, is often accused of being a psychical cause. 
It may, no doubt, hasten the outbreak of chorea in a child commen- 
cing to suffer from it ; but if fright is really capable of producing it 
in one who is healthy in all other respects, then we ought to have 
many more choreic patients, for there are many timid children who, 
by the slightest cause, are greatly frightened. 

See lays great stress upon the connection between chorea and 
rheumatism, discovered by himself. This connection, however, seems 
to be a very loose one indeed ; for, although it must be acknowledged 
that chorea may succeed to acute rheumatism, still the frequency of 
the occurrence has been very much over-estimated. In cities where 
much rheumatic sickness occurs, chorea ought to abound, and vice 
versa, but it is not so. In Genf, for example, according to HilUefs 
statement, there is a great deal of rheumatism and hardly any St. 
Vitus's dance. Moreover, if there were any actual connection be- 
tween them, then more girls than boys ought to suffer from rheuma- 
tism ; for it is well known that the former are predominantly subject 
to chorea. Just the reverse happens to be the case in rheumatism, 
which notoriously attacks more boys than girls. 

Pathological anatomy furnishes totally negative results in this dis- 
ease, which may, in part, be due to the rarity of fatal attacks. Fro- 
fiep found the odontoid process of the axis thickened in two cases, 
and describes it as a simple hypertrophy of its osseous substance. 
They are, on the whole, too solitary instances for any definite conclu- 
sions to be drawn from them. In fact, the true cause of chorea has 
not yet been fathomed, notwithstanding the numerous theories ad- 



400 DISEASES OF CHILDREN. 

vanced by Siehel^ sen. and jun. ; also the connection with worms, upon 
which great stress was formerly laid, in reality does not exist, for 
othermse chorea would probably be more frequent in worm regions, 
and be cured by anthelmintics, which, however, is not the case. 

Diagnosis and Prognosis. — The disease is usually so easily recog- 
nized, that even every la^nnan who has once seen it knows it again at 
a glance. It distinguishes itself by the uninterrupted and protracted 
duration of the symptoms, which last for many weeks, from all other 
convulsions that have been embraced under the not very appropriate 
denomination of chorea-like affections. To the latter belong stutter- 
ing, blinking, contractions of the angles of the mouth, the so-called 
weaver's and writer's cramp, over which, collectively, the will has 
some, although very little, influence. Besides, these affections occur 
only paroxysmally, or at the most diurnally, and are by no means as 
continuous as chorea. The disease described by Diibini under the 
inappropriate name of chorea electrica may be easily distinguished 
from chorea by the fact that, in this condition, according to Sasse^ 
there are headache and pains in the back, followed by electric t^witch- 
ings of the lower extremities, at first confined to one side, but soon 
extending over the whole body ; general convulsions, with perspirations 
and fever, now supervene, and the patient dies paral}i:ic in a few 
weeks. 

The prognosis in the great majority of cases may be set down as 
favorable, and that in three, or at the most six months, most of the 
children under a treatment that is at all rational Avill recover com- 
pletely. That kind of chorea which, according to some authors, runs 
into epilepsy and imbecility, depends, in fact, upon organic disease of 
the nervous centres, and consequently ought not to be classed with 
pure St. Yitus's dance. 

Relapses are not of rare occurrence; I have had two children 
placed under my care, who had completely recovered, were entirely 
free from muscular twitchings for several months, and were again at- 
tacked by a tedious chorea. A most decided disposition to neuralgia 
of all kinds remained behind in these children. It is a remarkable 
fact that the cure in boys, according to statistical compilations, takes 
place much slower than in girls ; in the former the treatment lasting 
seventy-four to eighty-one days, in the latter only thirty-three to 
tliirty-seven days. The latter averages seems to me to have been 
put rather too low. 

Therapeutics. — The main reason why a treatment directed to the 
cause can hardly ever be practised is, because the true cause of the 
disease has not yet been fathomed, as has already been shown. In 
tin's respect we should pay attention to the condition of the patient's 



DISEASES OF THE NERVOUS SYSTEM. 401 

residence, to the evacuation of worms, onanism, menstruation, and 
rlieumatic complications. 

Its treatment, with the countless number of remedies that have 
been recommended, can only, then, be properly appreciated when we 
bear in mind the spontaneous recovery from chorea. Indeed, a cure is 
often accompHshed in a few weeks, or, at the most, months, with 
almost any remedy, however absurd, but not intensely toxic. This su- 
perabundance of remedies is only found in two classes of diseases and 
which are diametrically opposite in their terminations, namely, in those 
which recover spontaneously, and in those that are almost certainly 
incurable. Epilepsy may be taken as a prototype of the latter. 

Abstractions of blood were considered appropriate when the dis- 
ease occurred with vascular excitement in robust subjects, and Syden- 
ham was brought forward as an authority for this practice. It seems 
to me, however, that every antiphlogistic measure is totally useless, 
if not actually injurious,, for the vascular excitement alluded to is not 
in the least critical ; and an anaemic condition, when the disease lasts 
for a long time, supervenes spontaneously, which condition is only 
accelerated by the previous abstractions of blood. Counter-irritants 
applied to the nape and spinal column, among which ointments of 
tartar emetic and sublimat., vesicants, and croton-oil, hold a high 
place, are useless tortures, and leave upon the poor patients perma- 
nently disfiguring cicatrices, which may, in future years, mar their 
attractions and mortify their pride. 

Derivatives applied to the intestinal canal are less objectionable, 
and the most appropriate remedies are the neutral salts, castor-oil, 
rhubarb, senna, and aloes, and, when the presence of intestinal worms 
is suspected, they may advantageously be combined with vermifuge 
remedies. Calomel and tartar emetic, on account of their subsequent 
constitutional effects, should be avoided, whether in large or small 
doses, for it is certain that they exercise no marked influence upon 
chorea. 

Wlien vascular turgescence is absent from the very beginning, em- 
pirical remedies may be resorted to at once. Among these, iron is, to 
say the least, the most rational, especially when the child is anasmic, 
and suffers from incipient chlorosis. The preparations of iron, and 
mineral waters containing iron, are recommended by the most ex]3eri- 
enced physicians as useful, and may be given for many weeks without 
detriment, even after the muscular jactitations have subsided. Serious 
constipation, resulting from this practice, should be relieved by the 
above-named aperients. So far as the effect of the remedy upon the 
nervous system is concerned, it is almost immaterial which prepara- 
tion is selected ; this may be decided on the grounds of its digesti- 
26 



402 DISEASES OF CHILDREN. 

bility, and the ease with which it is taken. Children, especially young 
ones, are not good at swallowing pills ; although they will swallow 
large numbers of cherry-pits with the greatest readiness. They bite 
pills, and retain the pieces in the mouth till they become soft, and 
their disgusting taste renders the object sought, viz., the introducing 
of remedies in a tasteless form into the stomach, unattainable. The ad- 
ministration of powders is, in the long run, inconvenient, as they have 
often to be frequently repeated at the apothecary's, on account of their 
deliquescent character. I, therefore, prefer the tincture of iron, and 
almost always use the ext. ferri pomati. which seems to be most easily 
assimilated. Homherg recommends ferrum cyanatum ; others the sul- 
phate and carbonate of iron. According to my experience, large doses 
of iron do not act more favorably upon the course of chorea than small 
ones ; besides, they are more apt to cause disturbances of digestion 
and constipation, and, for this reason, I do not consider it advisable to 
go beyond twenty to thirty drops pro die.. During convalescence, 
quinine, cinchona, and other tonics, may also be given with advantage. 

There are, in addition, a number of empirical remedies, which are 
more highly praised than brilliantly curative. The first to be men- 
tioned here are the metallic remedies, zinc, copper, and arsenic; and, 
of all the zinc preparations, the oxide is mostly preferred, given up to 
sixteen grains, three times daily; next, sulphate of zinc, in one to 
eight grain doses ; cyanide of zinc, daily, up to three grains ; and, 
lastly, ferrocyanide of zinc. Escolar praises valerianate of zinc, in two 
to twelve grains pro die. 

Sulphate and ammoniate of copper have been justly abandoned, on 
account of their nauseating action. The same should be done >vith 
Fowler's solution, an article which Henoch has recently so strongly 
recommended. 

It seemed quite pertinent to try narcotics in chorea, and various 
experiments have been made with them. Opium, belladonna, haschish, 
hyoscyamus, hydrocyanic acid, aconitine, and atropine, have been dis- 
carded long ago ; so, too, strychnine, first suggested by Trousseau — 
who has been most unfortunate with his therapeutic discoveries — ^has 
been abandoned by all rational physicians. 

In very severe chorea, where the children are unable to obtain any 
rest at night, temporary palliation may be derived from chloroform. 
But, when too often repeated, these inhalations affect the head un- 
pleasantly, and disturb the digestion. 

Animal and vegetable nervines have been quite as generally em- 
ployed as narcotics ; valerian, assafoetida, camphor, moschus, castoreum, 
colchicum, etc. Cold baths and douches are of decided benefit, and, 
as they are mostly disagreeable to the children, exert a good influence 



DISEASES OF THE NERYOUS SYSTEM. 403 

b\' inducing them to use every possible voluntary effort to avoid the 
necessity of their application. Under this influence, they may resist 
the involuntary movements to some extent. Dupuytren is an enthu- 
siastic advocate of cold baths and douches, and holds that, with their 
persistent use, every case of chorea is curable, in which declaration, 
however, he may possibly go too far. 

Of late, warm baths, and warm sulphur-baths in particular, have 
come into use, as many girls are unable to bear cold baths. For this 
purpose, four ounces of sulphate of lime are added to every bath, in 
which the children are allowed to sit for an hour every day. Hufz 
is of the opinion that, by this measure, the disease is shortened to 
twenty-four days ; Kohler^ however, observes, in this connection, that 
there are also cases w^here the disease becomes aggravated by it, and 
prohibits the further use of the sulphur-bath. 

As regards the psj^chical treatment of chorea, more harm than good 
is often done by harshness and severity ; but by this we do not intend 
to say that the stimulation of the volition should be entirely aban- 
doned. By kindness and promises of presents, the children should be 
urged to keep quiet until ten or twenty are counted ; they should be in- 
duced to make simple and easy efforts to control the movements of the 
hands and feet, and, when successful, should be praised, etc. 

Formerly, it was considered injurious to hold children firmly, 
or to tie them or bandage them in splints ; lately, however, cases have 
been reported where the apphcation of the splints — at first at night 
only, where the children, on account of the severity of the chorea, 
were unable to obtain any rest ; subsequently, also, by day and night, 
continued for many days — produced a remarkable improvement, and 
ultimately led to a cure (Monahan^ of Dublin). It certainly will only 
be necessary, in this treatment, to fix gently the extremities, by prop- 
erly bent and padded splints, while it will seldom be possible to re- 
strain the motions of the body. This method, at any rate, deserves a 
further trial. 

The little voluntary exercises, recommended above, have been more 
systematically developed by the Swedish-movement cure, by first prac- 
tising passive, then the so-called duplicate, and, finally, active compli- 
cated movements. 

The dietetic treatment is of little importance. The irregularly and 
badly-fed children of the poor recover as rapidly as those of the wealthy 
class, where every morsel of bread and meat is first subjected to the 
physician's examination before it is given to the patient. A healthy, 
dsy residence, and the enjoyment of fresh air, accelerate the cure ; 
mental exertions retard it, and those addicted to onanism it is often 
entirely impossible to cure. 



404 DISEASES OF CHILDREN. 

If we make a resimie of the entire treatment, we shall find it to con- 
sist essentially of cold baths and douches, of the administration of 
iron, and prudent psychical strengthening of the will. In the severest 
form, chloroform is to be preferred to narcotics, and a trial with splints 
would also be rational. 

(4.) Choeea Majoe (the Great St. Vitus's Dance) — Chorea Ger- 
ma:n-orum. — A very rare alBPection, in w^hich term spasmodic diseases 
of various kinds are included. Chorea major attacks girls almost 
exclusively, and only those w^ho are approaching puberty. The 
essential character of this disease consists in this, viz. : the children 
are attacked by paroxysms of regulated movements, apparently exe- 
cuted with consciousness and proper will, in which a peculiar potency 
of the mental abilities manifests itself. The transition into somnam- 
bulism, animal magnetism, miraculous mania, etc., is very apt to hap- 
pen, and it requires the utmost professional sagacity to strike the exact 
boundaries between imposition, or deception, and an actual pathologi- 
cal state. 

Symptoms. — The phenomena vary so much in individual patients 
that it is difficult to sketch a picture of symptoms apphcable to all 
cases. The outbreak of the paroxysm is almost always preceded by 
psychical and corporeal premonitions. To the first belong sadness, 
great moodiness, depression of spirits, fear of phantoms, active 
dreams, and restless sleep; to the latter, palpitation of the heart, 
cardialgia, disturbances of digestion, anorexia, headache, and pain in 
the back, may be added. 

Finally, actual paroxysms develop themselves. The patients 
begin to make apparently voluntary, sometimes simple, sometimes 
again complicated movements, which they execute with unnatural 
strength, steadiness, rapidity, and perseverance. The patients are 
seen to perform the movements of swimming, climbing, jumping, 
dancing, crawling, and attempting the most wonderful contortions of 
the body. 

In others, again, it approximates more to pure psychical alienation 
or exaltation ; they begin to declaim, compose, preach, and sing with 
great volubility, or to talk nonsense with lofty pathos, or to imitate 
the cries of beasts. 

The influence of the will is not always completely abolished ; some 
cannot be roused from the paroxysm by any means, not even by in- 
flicting any amount of pain, while others, again, are recalled to con- 
sciousness by simply dashing water in the face. 

This condition most resembles the incomplete narcotism from 
chloroform, in which the patients are in an unusual state of excitement. 
Sometimes these paroxysms last only a few minutes ; then, again, 



DISEASES OF THE NERVOUS SYSTEM. 405 

several hours ; and end either by the patients becoming more calm, 
or then waking up as from a dream, and looldng about in surprise, or 
by relapsing into a profound sleep, often lasting several hours. The 
recollection which the patient has of what transpires during these 
paroxysms is variable. Some recollect about as much of what was 
said and happened in the paroxysm as is remembered of a dream, 
or they retain nothing at all of it in the memory. 

During the attack, external irritation induces no reflex movements, 
or but very slight ones, a fact which will always give rise to a sus- 
picion that it is feigned. When, for instance, a girl tolerates pinching, 
pricking, and blows, without flinching, but sneezes when her nostrils 
are tickled, shivers for an instant when cold water is poured upon her, 
and when burned arouses, complains of pain, there is usually no actual 
disease at the bottom, but only a mental derangement, by means 
of which the nervous child is seeking to excite sympathy. 

Here, again, the course of the entire complaint is very variable. 
Every thing may be completed with a single paroxysm, or several may 
follow each other at greater or lesser intervals, varying from a few 
hours to many days. When the period between two paroxysms is 
very short, and only a few days in duration, the general condition 
barely ever becomes normal, for the patient complains of muscular 
debility, and is whimsical and petulant, and suffers disturbances 
of the digestive organs. The whole affection generally lasts only a 
few weeks or months, and, with the appearance of the menses, com- 
plete recovery is estabhshed. Relapses have also been observed in 
this disease, during which the catamenia disappeared, or became 
irregular. A state of extraordinary nutrition, and a disposition to 
obesity, take place in these girls after recovery, especially in the so- 
called spiritualists. 

As regards the sex, the disease, according to a statistical report by 
TF?c^6, who has collected one hundred and twenty-six cases, attacked 
eighty-eight girls and thirty-eight boys. Of one hundred and seven 
patients in whom the date of the commencement of the disease could 
be ascertained, eighty-four were between the tenth and twentieth 
year of age, and, of these eighty-four, sixty-two were between the 
tenth and sixteenth year. An hereditary disposition is often observed, 
and these patients are almost always brought up by hysterical, eccentric 
mothers. 

In regard to the organic basis of this disease, conjectures can only 
be formed. No certain parts of the brain are affected in any case, 
otherwise the symptoms would be more constant and uniform ; and in 
no case can an inflammatory exudation or a permanent alteration of 
the form of the brain properly be assumed, because the disease al- 



406 DISEASES OF CHILDREN. 

most always terminates in recovery, and only exceptionally ends 
in paralysis or epilepsj^ In fact, the entire activity of the brain has 
simply attained to a high degree, and this disposition sometimes 
manifests itself most in great irritability of the motor nervous system, 
and sometimes, again, more in an exaltation of the psychical depart- 
ment of the brain. Hasse very fittingly observes : " There is only one 
condition which can be suggested to explain this singular disease, 
namely, sleeping and dreaming." When we bear in mind that such 
manifold, sometimes uniform, sometimes again changeable perform- 
ances transpose the dream into actual action, we have in reality all 
the phenomena of the great St. Vitus's dance. 

What tends to complete this analogy is, the circumstance that the 
paroxysms begin with a kind of sopor, a stupefaction, and terminate 
with an awakening, as from a dream ; so that in chorea major, accord- 
ing to this view, we have nothing else than a potential, lively dream, 
with great irritability of the sensorium. 

The prognosis^ inasmuch as the disease is not fatal, must be favor- 
able. The paroxysms almost always cease, although not until after a 
long time, and these persons always retain for life a something singu- 
larly bizarre^ w^hich begets a cautiousness about intercourse with them. 
They sometimes relapse into religious enthusiasm, sometimes into 
exalted love-affairs, and are rarely known to make quiet, sensible 
women. 

Treatment. — There are no medicines which will certainly prevent 
the attacks, not even such as are capable of arresting the disease ; but the 
general state of the system often furnishes opportunities for therapeu- 
tic measures. These girls, as a rule, suffer from chlorosis and obstinate 
constipation, on account of which iron and laxatives are usually indi- 
cated. The constipation, in most instances, is so difficult to overcome, 
that powerful drastics have to be employed, with which finally a few 
copious evacuations are obtained. 

The desideratum is always the psychical treatment. If the parox- 
ysms once become the subject of public wonder and town talk, they 
will not cease again for years. It is therefore necessary, first of all, to 
remove the child to a suitable neighborhood, and at the outbreak of 
the paroxysms remove it from its excited parents into private rooms. 
The attacks should be allowed to pass off quietly, and when passed 
they should not be mentioned. Never should the child be told what 
it said and did during the paroxysm. 

All exciting studies and society should be strictly avoided ; suitable 
bodily exercises and even active exertions have the double advantage 
that the digestion is thereby stimulated and the mind is diverted from 
pernicious fantasies. Hasse holds that the experiments with animal 



DISEASES OF THE NERVOUS SYSTEM. 407 

magnetism, and all experiments generally, are objectionable. In the 
only case which stands as a precept for me, I found cold water of de- 
cided benefit, and the paroxysms ceased entirely after the extremely 
eccentric child was separated from her half-demented mother and 
placed with her sensible grandfather. The fits consisted in this, viz. : 
the girl would suddenly sit down upon the floor, set up a peculiar 
grunting cry, and at the same time revolve with lightning-like rapidity. 
A few glasses of water dashed with force into her face soon brought 
her to her senses again, and after this had been repeated five times 
the paroxysms did not return. 

(5.) Epilepsy, Moebus Sacer, Comitialis, Caducus, Fallsucht, 
Fallixg-sickness, Fits. — By epilepsy we understand convulsive 
paroxysms which recur often and are accompanied by sudden abolition 
of consciousness and of the functions of special sense. 

Epilepsy and its causes, the kind and the effects of the paroxysms, 
are so minutely treated of in the works of special pathology, that it does 
not seem necessary to here give a very exhaustive description, and the 
student may therefore be referred to the excellent delineations found 
in the works of Ganstatt^ Momherg^ and Hasse. A few peculiarities 
appertaining to children only will be mentioned here. 

Symptoms. — Very often, in adults, remote and almost always near 
premonitions (aura) are observed. The former consist of an altered dis- 
position of the mind, great irritability, headache, vertigo, and a feeling 
of weariness. The latter, which immediately precede the attack, and 
are often so brief that the patients have barely time to prepare them- 
selves for it, consist in headache, giddiness, tinnitus aurium, darkness 
before the eyes, perception of bad odors, trembling, chilliness, oppres- 
sion and palpitation of the heart. In children the remote premonitions 
are mainly unnoticeable, for the reason that the attacks are much more 
frequent, recurring daily, or at least weekly, and therefore no very dis- 
tinct prodromata appear. The near premonitions, the aura, are also 
unheeded by most children, because they pay very little attention to 
themselves generally. Indeed, while quietly playing, the child is usu- 
ally surprised by the paroxysms with sucl\ lightning-like rapidity 
that in general no aura can be assumed to exist. 

As regards the paroxysm itself, it almost regularly begins with an 
inarticulate, unnatural cry or moan, and with tears flowing from the 
eyes, by which it is claimed that the commencement of the paroxysm 
must be painful. All subsequent perception of pain, however, is abol- 
ished by the rapidly-supervening unconsciousness. During or immedi- 
ately after the cry the child falls down suddenly ; it does not, however, 
first sink down upon the knees and then on the floor, but di'ops down 
with such force that it seems as if prostrated by a violent blow. The 



408 DISEASES OF CHILDREX. 

direction in wliicli it falls is decided by tlie position the body was in 
at the time of the seizure, and has no pathognomonic significance. 
Often it is dashed to the ground with such violence that serious inju- 
ries happen to it which may lead to death. It may be assumed with 
tolerable certainly that the more sudden the invasion and the pros- 
tration, the more violent and protracted "vvill be the jDaroxysm. 

After the child has fallen, the most variable convulsions begin, 
sometimes tonic, sometimes clonic ; sometimes, again, they alternate. 
Epilepsy of children particularly distinguishes itself from that of the 
adult by the inequality of the spasms. ^Yhile, in adults, especially 
men, one fit runs just the same course as another, in children the 
duration and kind of the con\-ulsions often vary very much ; nor does 
the same group of muscles always participate in the contractions. The 
most frequent phenomena are gnashing of the teeth, tetanic jerkings, 
and contractions of the extremities, contractions of the thumbs, back- 
ward cur™g of the spine, and the most multiform contortions of the 
muscles of the face and eyes. Still, none of these symptoms are so 
constant as that their absence should render the diagnosis of epilepsy 
doubtful, when the other diagnostic signs correspond. The popular 
supposition, that convulsions in which the thumbs are not contracted 
do not belong to epilepsy, is totally devoid of foundation. This symp- 
tom, though of frequent occurrence, is absent in a considerable number 
of otherwise well-pronounced cases. 

In more violent paroxysms the respiratory muscles also participate, 
in consequence of which the breathing does not go on properly and 
rhythmically, and the expiration in particular, owing to the constant 
contractions of the muscles which ought to be relaxed, becomes labo- 
rious. As a result of this,, the thorax becomes distended and the 
respiratory sounds are but feebly heard, if it be at all possible to aus- 
cultate the lungs. The general jactitation of the body, and the rattling 
in the throat of the accumulated mucus, however, often make an ex- 
amination of the lungs impracticable. The direct effects of this dis- 
turbance of the circulation are : cyanosis, swelhng of the veins of the 
neck, injection of the ey^s, tumefaction of the tongue and entire face, 
and finally even bleeding of the mucous membranes of the conjunctiva, 
nose, and mouth ; not all haemorrhages from the mouth, however, pro- 
ceed from this source. Oftener they are the effects of womids of the 
tongue inflicted by the teeth during the paroxysm. 

The cardiac muscle seldom participates in the spasms ; the pulse, 
in consequence of the general exertions, is indeed somewhat ac- 
celerated ; still, it is not unrhythmical, and, immediately after the com- 
pletion of the paroxysm, returns to its normal condition. 

The urine and stools pass involuntarily more frequently in cliildren 



DISEASES OF THE NERVOUS SYSTEM. 409 

tlian ill adults, and white or even bloody foam at the mouth is a-lso 
more frequently seen in them than in adults, because the secretion 
of mucus and saliva is generally much more plentiful. In conse- 
quence of the great bodily exertion, a profuse perspiration breaks out 
at the end of the fit, the strong contractions subside, and the children 
wake up as from a dream, and, sighing deeply, stare about bewil- 
dered. Hardly ever do the attacks last longer than five minutes, but 
to the anxious parents the time naturally seems much longer, and is 
unintentionally greatly exaggerated. Although there are many adult 
epileptics who barely sufi'er one paroxysm a year, the children afflicted 
mth this disease are attacked by it at least once a week ; still, no ap- 
proximation to any regularity can be noticed : sometimes long pauses 
ensue, sometimes the paroxysms appear every day, sometimes several 
follow each other at the same hour, so that it was actually thought 
that it had an intermittent character, and quinine was therefore ad- 
ministered — always, of course, without the least efi"ect. Sometimes, 
again, they appear at different times of the day. 

The indi-vddual symptoms are not always so conspicuously developed 
as the above delineation declares, and there are also many milder forms 
which have been covered by the name of epileptic vertigo. In this 
form the child does not fall do^vn ; it may stagger somewhat at the 
most, seek to sit do^vn, or, when attacked while walking, continue on 
its way as if in a dream, with rigidly-contracted features. This con- 
dition barely ever lasts longer than a minute, but recurs often during 
the day. Some children have paroxysms of different degrees of seYcr- 
ity, sometimes only a slight giddiness, sometimes violent convulsive 
fits, with prostration. There are the most multiform gradations, from 
slight giddiness, up to horrible paroxysms, attended with rupture of 
muscles, fractures of bones, and hemorrhages. After a mild attack 
the children recover promptly, and eat and play as before, but after a 
severe one they sink into a long and profound sleep, from which they 
awake with headache and fatigue, which generally last for several days. 

During the intervals the state of the health differs according to the 
duration, severity, and frequency, of the paroxysm. Some cliildren, 
who only suffer from the milder form, retain their healthy appearance, 
and continue to develop both bodily and mentally ; others, however, 
especially after an epilepsy of several years' duration, acquire a brut- 
ish expression of countenance, become morose, choleric, ravenous, and 
retrograde instead of progress in their mental development. Their 
physical development is also arrested, and they ultimately degenerate 
into complete cretins ; cicatrices and contusions, the effects of the falls, 
are found on the body ; the teeth, from the constant grinding, are worn 
off; and the tongue is fissured by the wounds it has received. 



410 DISEASES OF CHILDREN. 

■ But milder forms of the disease are borne throughout life without 
any ill consequences, as is shown by the well-known fact that many 
persons eminent for their mental endowments have suifered from 
epilepsy to the end of their lives. The most prominent of this class of 
epileptics are : Julius Ccjesar, Mohammed^ Charles K, Petrarch^ Fa- 
Mus Columna^ Housseau, and Napoleon X 

The course of epilepsy is decidedly chronic, for the patients retain 
it for life and take it with them to the grave ; the commencement is 
eminently acute, for in most cases very uncertain premonitions pre- 
cede it, and the disease can be diagnosticated only after the first 
paroxysm has appeared. The younger the child, the more frequent 
the paroxysms ; and they diminish in frequency with advancing age 
till about the period of puberty, when they again become frequent, 
and so continue for more or less time, and finally assume a more con- 
stant form, and the intervals become more uniform. The disease is 
decidedly aggravated by onanism, spirituous drinks, and all kinds of 
mental excitement. No scientific connection can be demonstrated to 
exist between epilepsy and the growth and decline of the moon, a 
very common supposition among lay people. On the other hand, the 
chmate, or perhaps only the temperature, is not wholly devoid of in- 
fluence in some cases. I am acquainted with a man who in the cold 
winter months suffers from a mild epilepsy, but in summer is entirely 
free from it. For the last two years he has spent the winter in Al- 
giers, and has been free from the attacks. 

, Epilepsy is arrested during acute febrile diseases, but is exacer- 
bated by chronic affections, such as helminthia, constipation, and neu- 
ralgia. The influence it exercises upon the mental functions has al- 
ready been spoken of above. 

The usual terrnination is, in fact, in death. Epilepsy, it is true, 
does not prevent the child from growing up to thirty or forty years 
of age, but it appears from statistics that it very seldom outlives 
this age. Serious cases usually run into other cerebral diseases, such 
as cerebral apoplexia, mania, or imbecihty, which are soon fatal. 
Recovery is a very rare occurrence ; less so, however, in children than 
in adults. In children, epilepsy has been seen to disappear after the 
cutting of the four molar teeth, and sometimes upon change of resi- 
dence. Additional minutise upon this point are to be found in the 
section on etiology. Recovery either takes place suddenly or gra- 
dually. The last paroxysm is either just as violent as the previous 
one, or the fits disappear gradatim, and first merge into mild epileptic 
vertigo, and finally disappear. 

Etiology — Difficult as it is, in most cases, to fathom the true 
cause of epilepsy, a particularly careful examination, and close inspec- 



DISEASES OF THE NERVOUS SYSTEM. 



4:11 



tiou of the body, must nevertheless be practised, for it may discover 
something upon "vvhich to found a rational treatment. The form of 
the attack furnishes little or no data for the etiology. Even the kind 
of aura preceding the attack is not available in children, since in gen- 
eral it is very short, and is immediately forgotten after the fit. 

As regards the age^ epilepsy spares none. Young children in gen- 
eral rarely suffer from true epilepsy, as we might expect, if the more 
frequent eclampsia be regarded as a distinct disease. Eclampsia is 
easily distinguished from the disease under consideration, by the fact 
that it almost always occurs at the breaking out of an acute affection 
only ; that the general condition of the patient, after the termination 
of the convulsions, is not restored; and that it is often fatal, while 
epileptic attacks are almost always devoid of danger. 

According to a statistical compilation by Beau^ two hundred and 
eleven epileptics present the following history : 



Congenital epilepsy Vl 

From birth up to 6 years of age 22 

" beginning of 6tli to 12th year. . 43 

" " 12th to 16th " 49 

" " 16th to 20th " 17 



From beginning of 20th to 30th year 29 

" 30th to 40th " 12 

" 40th to 50th " 15 

" " 50th to 60th " 5 

" " 60th to 61st " 1 



It will be seen that two-thirds of these patients, at the invasion of 
the disease, had not attained the sixteenth year. 

As regards the secc, it is generally assumed that in adults more wo- 
men are epileptic than men. I am not aware of any tabular compilations 
of epilepsy in children arranged according to the sex, but, from the 
cases which I have so far observed, the statement above given as to 
adults will not apply to children, for I can recall to mind more epilep- 
tic boys than girls. 

The hereditary nature of epilepsy is generally acknowledged, even 
among lay people. It is by no means necessary that the inherited 
epilepsy should also be congenital, i. e., occur immediately after birth ; 
it may remain latent for a long time, and only come on at the period 
of puberty, or even still later. Congenital epilepsy is especially ob- 
served when epileptic mothers suffered from frequent paroxysms dur- 
ing pregnancy. In children under one year of age, it is very difficult 
to distinguish it from eclampsia, or general convulsions, and it is only 
characterized by its chronic course, and by its not being followed by 
any acute disease after the fit has passed off. 

Epilepsy sometimes overleaps a whole generation, and appears in 
the second with all its former severity, or it attacks only portions of 
the descendants, sometimes the male, sometimes the female. 

Besides the causes already assigned, there are many others men- 



412 DISEASES OF CHILDREN. 

tioned in the text-books ; few of them, however, are demonstrable. 
Thus, for examj)le, it is claimed that great mental excitement, espe- 
cially from fright or anger, is a very potent cause. If this were the 
case, the great majority of persons ought to be epileptics. Various 
forms of epilepsy, according to the locality of the aura, have been dis- 
tinguished, such as epilepsia spinalis, thoracica, abdominalis, nephri- 
tica, genitalis, and peripherica, without it being possible, however, to 
confirm these varieties by post-mortem appearances. 

An epilepsy excited by tuberculosis chiefly occurs in children. A 
large tubercle in the bronchial glands, or in the brain, an hypertrophied 
tuberculous lymphatic gland exerting a pressure upon the circum- 
jacent nerves, are sovae of the supposed causes of epilepsy. In rare 
cases, cryptorchidismus is the alleged cause. These recover after the 
testicle has descended, or, if arrested in the canalis vaginalis, after the 
testicle is removed. Of the peripheral causes, the most frequent is the 
eruption of a cuspid or wisdom tooth, after which a recovery has been 
seen to ensue. Epilepsy is repeatedly reported to have been cured by 
the excision of a cicatrix. These instances, however, are very rare, al- 
though all epileptics, since that fact first became known, are closely 
examined for cicatrices, which, when found, are excised with the best 
of hopes ; still, the paroxysms are generally in no way afi'ected by this 
operation. 

The post-m,ortem, examinations of epileptics furnish no uniform 
results whatever. They sometimes turn out to be totally negative. 
In many cases the most variable lesions of the brain are found, atrophy 
and hypertrophy, induration and softening, plastic and serous exuda- 
tions on the meninges, haemorrhages, tubercles and abscesses in the 
substance, hernia, exostosis, caries or necrosis of the cranial bones. 
In congenital epileptics, in addition, there are found asymetrical cranial 
bones, flattening of the forehead, a broad or pointed occiput ; the bones 
of the skull are sometimes remarkably thickened ; sometimes, again, 
attenuated. Elliotson is perfectly correct when he says that this kind 
of cranial bones does not necessarily produce epilepsy. It is, how- 
ever, certain that this evil very frequently occurs in imperfect develop- 
ment of the brain. In the older medical works, vascular congestions 
of the brain and spinal cord play an important part, but lately these 
anomalies of the distribution of the vessels have justly come to be re- 
garded as phenomena occurring at the time of, or even after death. 
The post-mortem appearances in the other organs may vary still more 
than those of the brain ; in other words, epileptics may perish not 
only from the efi'ects of this chronic malady, but also from all pos- 
sible acute and chronic diseases. On carefully dissecting the nervous 
centres, neuromata have also been frequently found. 



DISEASES OF THE NERVOUS SYSTEM. 413 

Diagnosis. — The main difficulty in the diagnosis in female adults is 
to distuiguish hysterical attacks from the truly epileptic. But that is 
chiefly and especially accomplished by the circumstances that, in the 
former, consciousness is not wholly abolished, and for that reason also 
no prostration and no wounds from the teeth occur. In children it is 
not hysteria but eclampsia that may be confounded with epilepsy. It is 
impossible to distinguish an eclamptic fit by itself from an epileptic one, 
but the condition by which it is succeeded furnishes a correct differen- 
tial sign. After an eclamptic attack, the child never feels perfectly 
well ; it is always feverish, suffers from an acute exanthema, or some 
other acute disease, or vomits at least the undigested contents of the 
stomach. Epileptic children are perfectly well on the same, or, at 
least, on the next day, and are free from all signs of fever. 

Spoiled children sometimes also take it into their heads to feign 
epilepsy, in order to escape corporeal chastisement, for they observe 
that triily epileptic children are never very severely punished. Those 
who attend large schools, and inmates of educational institutions, have 
great facihties for acquiring this simulation, for they have frequent 
opportunities to observe epileptic children. It is not always easy to 
distinguish the feigned from the genuine epilepsy in children who 
are refined and possess imitative talent. Under no circumstances 
should simulation be assumed unconditionally, so long as there is no 
positive proof. The tutors should be instructed to treat such children 
with the same indulgence as they would treat genuine epileptics, and 
should rather allow themselves to be imposed upon for a time than 
to aggravate the condition of a really sick child by undue severity. 
It is, however, scarcely possible that the impostors will ever succeed in 
imitating the strong turgescence of the face during the paroxysms, 
and still less the subsequent abnormal pallor. It is very difficult, 
according to Marc, to extend the thumbs and open the hands of a 
genuine epileptic, but, after this has once been accomplished, the hand 
will stay open. The feigner is not aware of this peculiarity, and will 
shut his fist again as soon as he feels no resistance. In regard to this 
sign, however, a great number of epileptics have yet to be examined 
before undoubted value can be awarded to it. 

Treatment. — The practical therapeutics of epilepsy is perhaps the 
most extensive, and at the same time most unprofitable of any disease. 
All possible remedies are administered, and such brilliant success is 
ascribed to them, that it requires great medical skepticism to doubt 
them. The supposed good effects of many remedies may also be 
based upon error, or at least self-deception and imperfect observa- 
tion, but a correct inference as to their value is rendered still more 
difficult by the circumstance that, from all remedies, no matter what 



414 DISEASES OF CHILDREN. 

may be their chemical composition, a decided improvement is always 
obtained at first. This observation, first made by Esqidrol^ has since 
been confirmed by great numbers of observers, and clearly shows 
that the psychical state possesses great influence upon the morbid 
process. 

The treatment itself comprises (1), the prophylactic; (2), the re- 
moval of the cause ; (3), the use of specifics ; and (4), a general bodily 
and mental hygiene. 

(ad 1.) The prophylactic treatment, on account of the acknowl- 
edged hereditary character of the disease, consists in restraining epi- 
leptics from marrjdng, and in preventing an epileptic mother from suck- 
ling her child, and in treating the children of epileptic parents with the 
utmost possible forbearance. Over-stimulation of the nervous system 
by early and exacting studies, or by exciting impressions, such as scold- 
ings, chastisements, ghost-stories, etc., is to be avoided. 

(ad 2.) The treatment directed to the cause, where the cause can 
really be fathomed, is by far the most favorable. But, unfortunately, 
it is much less possible to discover the true cause than is usually 
supposed, for the statements of the relatives, of a fall, fright, or of a 
grave sickness recovered from, etc., should be received with the ut- 
most caution. First of all, the child should be undressed, and every 
part of the body subjected to a critical examination ; the assertion of 
the relatives, that the entire body is normally formed, should never in- 
duce us to forego this examination. By it a tumor pressing upon a 
nerve, a cicatrix involving a nerve, or a foreign encysted body, liaa 
often been discovered, located in the course of the peripheral nerves* 
whose removal was followed by the disappearance of the epilep- 
tic convulsions. It is even stated that epilepsy has been cured by the 
excision of corns, and extraction of carious teeth (?). In this peripheral 
epilepsy, the exsection of the afi'ected nerve is attended by the surest 
efi"ects. The condition of the brain and its adjacent parts, of course, 
deserves special attention. The cranial bones should be carefully ex- 
amined for depressions, otorrhoea, S}^hihtic exostosis, etc. ; chronic 
congestive conditions of the brain should be relieved by revulsions 
to the alimentary canal, or by derivatives, and counter-irritants, such 
as vesicants, irritating ointments, setons in the nape of the neck, and 
even moxas. With this object in view, the carotids have even been 
tied, and recently a trial of compressing them has been made. Both 
these measures, however, proved inefi*ectual. Trei3hining of the for- 
merly injured cranial bones is also indicated, in cases where the par- 
oxysms do not improve after the cicatrix of the scalp has been ex- 
cised. Tlssot thinks so highly of this operation, that he recommends 
it to be tried in all desperate cases. 



DISEASES OF THE NERVOUS SYSTEM. 415 

"When worms are present, they are to be removed by the methods 
suggested in the chapter on " Intestinal Worms." Disposition to con- 
stipation should be obviated by frequently-repeated clysters, or aperi- 
ent waters. The genitals should be closely examined for evidences of 
onanism. Rapidly-cured eruptions of the skin and arrested habitual 
sweatings may sometimes be reestablished. 

The treatment of the paroxysm itself essentially consists in pro- 
tecting the body against injury. The furniture of the room occupied 
by the patient should not present sharp, exposed corners, the stove 
should be guarded, the floor covered with carpets, and the couch should 
be low, so that the patients may not sustain serious injury should they 
happen to fall from it during their nocturnal attacks. They should 
never be left without surveillance. All restraint at the commence- 
ment of an attack is injurious, and tight garments should be loosened. 
All measures employed during the paroxysm, such as frictions, sprink- 
ling of cold water, compression of the carotids, magnetism, inhalation 
of irritating gases, opening of the thumbs, and tying the face, how- 
ever popular these may be, are either useless or injurious. 

The attempts in a protracted aura to prevent the fit itself have not 
heretofore proved very successful. On the whole, only those parox- 
ysms which are of peripheral origin may possibly be arrested. The 
remedy consists in tying the affected limb tightly with a strong liga- 
ture, which is gradually slackened after several hours. By this means 
it is certainly possible in some cases to prevent the paroxysm alto- 
gether ; in others, however, it causes the utmost dread and apprehen- 
sion, and the patients insist upon the speedy removal of the ligature, 
preferring to suffer the convulsions. Children generally rally very 
rapidly after the fit, so that there seems to be no occasion for an after- 
treatment. Sopor, a feehng of weariness or nausea, which occasionally 
remain behind for some time, are quickly relieved by a sinapism or a 
derivative foot-bath. 

(ad 3.) The anti-epileptic specific remedies have lately become so 
fearfully numerous, that the denomination " specifica " may be re- 
garded as a veritable disgrace to the physician. It would be of no 
use to copy here the whole list of the anti-epileptica that were and 
still are used. Those most extensively employed only will be briefly 
mentioned. 

For the treatment of the recent attacks the following remedies, ac- 
cording to Kohler^ are appropriate : 

(1.) Rad. artemisise vulgar., 10 to 20 grs. of the fresh powder, 
given as short a time before the fit as possible. 

(2.) Rad. Valerianae, daily, 3ss to 3j of the fresh powder. 

(3.) Flores zinci, gr. j to x, or in as large doses as possible, is recora- 



416 DISEASES OF CHILDREN. 

mended by many physicians, especially Herpin. The treatment should 
be continued for three months. Valerianate of zinc is, in fact, a com- 
bination of two remedies for epilepsy, but the effects of the zinc do 
not seem to be improved in the least by the valerian. Others prefer 
the sulphate of zinc, and give it in j to'v grain doses pro die. 

The following remedies are employed in older cases, and in which 
those just described have proved ineffectual : 

(1.) Ammoniate of copper and the various preparations of copper 
-with which, owing to their nauseating properties, it is not usually pos- 
sible to go beyond -J, at the most \ grain doses. 

(2.) Argent, nitrat. is recommended by many physicians, especially 
by Sehn. In children it must be given in ^ to 1 grain daily for years. 
There seems to be no very great danger of the skin becoming gray 
from it, as that happens in only a very few patients. I, for instance, 
notwithstanding a most extensive employment of this remedy, have 
never yet observed that result. The great precaution that is taken to 
introduce the nitrate of silver, as such, into the stomach, is probably 
superfluous, for the combinations of chlorine which are constantly 
present in the gastric secretions must certainly convert it quickly into 
a chloride. 

(3.) Mercury, internally in the form of calomel, sublimate, or cinna- 
bar, or externally in the form of blue ointment, is only indicated when 
there is a suspicion of the presence of Tophi syphihtici. It, however, 
must not be forgotten that, on account of its consecutive constitutional 
effects, it may prove very injurious. 

(4.) The additional metallic remedies to be mentioned are, acetate 
of lead, oxide of zinc, nitrate of bismuth, the preparations of iron, 
manganese, and arsenic. 

(5.) The narcotics have been extensively employed, and are in- 
variably found in the numerous secret remedies. No certain curative 
effect has been derived from opium, but a rapidly-developed imbecihty 
has very often indeed been observed from its use. Rad. belladonnge, 
and latterly atropine in gr. -^ to y^, chloroform, ether, ext. stramonii, 
hyoscyamus, digitalis, agaricus muscarius, narcissus, pseudo-narcissus, 
nux vomica, and strychnine (gr. -j^ to J pro die), have been repeatedly 
recommended. 

(6.) Finally, there is yet a list of vegetable and other kind of 
remedies from the various classes of the materia medica : solium 
palustre, indigo, viscum quercinum, sedum acre, folia aurantiorum, 
radix p^oniee, cotyledon umbilicus, Scutellaria geniculata, assafoetida, 
moschus, castoreum, camphor, amber, cinchona and its preparations, 
rad. dictami albi, pepper-corn, turpentine, Dipel's oil, phosphorus, and 
the mineral acids. 



DISEASES OF THE XERYOUS SYSTEM. 41 ^ 

(ad 4.) The general bodily and mental hygiene is of great impor- 
tance. The diet should not be too nutritious, and alcoholics should be 
prohibited altogether, for in many patients a iit is induced by indiges- 
tion, and, still more srn-ely by a use of alcoholic drinks. Constipation 
should never be permitted. It is of especial benefit, in all cases, to 
stimulate the functions of the skin by cold and warm baths, so as 
to produce copious perspiration. Bodily exercise, especially in the 
open air — for example, in garden and field — ^often effects a complete 
cure. Of the bodily exertions, only such, of course, are to be chosen 
as will not of themselves induce a paroxysm ; riding and swimming, 
for example, can hardly be recommended. Travelling and change of 
climate, particularly changing a colder for a warmer, often bring 
about a suspension of the paroxysms, to which the diversion and the 
agreeable state of the mind which result from some travels may con- 
tribute not a little. It is a weU-known fact that children are seldom 
attacked while playing, or when occupied, but only at night, or when 
they sit morose and idle. 

They should not be encouraged to forego mental exertions, for the 
mind, if not exercised, sinks into a state of unhealthy torpor. But 
the hours of study should be so arranged as to allow sufficient inter- 
vals of rest ; and they should be taught in such a manner as to inter- 
est them in their studies, and thus render learning comparatively easy 
— a fact, however, every tutor does not know, and a result he does 
not know how to accomplish. These children should not, if possible, 
be sent to the public schools, for most of them learn much slower than 
healthy children, and, on account of the fits, are feared and even de- 
rided by the latter. Under these circumstances the mental depression 
becomes considerably aggravated, and it is a serious detriment to a 
person, in after-life, that his previous affliction should be generally 
known, although he may have been subsequently cured of it. 

APPENDIX. 

Diseases of the Mind. — In children, hnheciUty and idiotism pre- 
dominantly occur. It is necessary to discriminate between real idiot- 
ism and arrested or retarded development of the mind, although there 
certainly are steps of transition where this distinction is difficult to 
make. The development of the body, also, in real idiots, is always 
visibly retarded, while many children, with extremely feeble mental 
endowments, the' so-called enfants arrihres^ corporeally thrive all the 
more. Marked abnormalities are also always detected in the skull of 
idiots, which are due to the smallness of the brain. 

The circumference of the skull is small, the head is compressed or 
pointed from before backward, or from side to side, in contrast to 
27 



418 DISEASES OF CHILDEEN. 

endemic cretinism, which is found most typically marked in some of 
the valleys of the Tyrol, and which manifests itself by the form of the 
skull ai^proaching more that of a square, and by hy]3ertrophy of the 
bones. 

Idiotism, depending upon smallness of the brain, occurs sporadi- 
cally, and seems to be promoted by intermarriage. 

Out of one hundred idiots, according to statistical compilations by 
Semis^ of Kentucky, fifteen were the progeny of m.arriages that had 
been formed between cousins. Cretinism occurs chiefly in narrow, dark 
valleys, and is very seldom observed on the jDlains. "V^Hbether coitus 
during intoxication will also produce idiotic children, is much doubted, 
for, if this were the case, these would undoubtedly be more numerous. 

Symptoms. — The degree of idiotism varies exceedingly. In the 
extreme degree, all mental action is defective, and the organs of sense 
perform their fimctions very imperfectly. Deafness is frequent. Com- 
plete idiots are incapable of learning to speak; they do not even 
attemjDt, by stammerings or mutterings, to make themselves under- 
stood ; the cry is rough and monotonous. The children learn to sit 
very late, but never to walk. They swallow greedily the food allowed 
them, without tasting it ; they allow the urine and stools to pass off 
uncontrolled. In consequence of this torpor, the muscles of the body 
become atrophied, and the integument covered with ulcers, from press- 
ure and filth. Fortunately, most of these individuals die of compul- 
sions during the first dentition, and never attain to puberty. 

In those cases of less severity the children learn to stammer and 
to walk, and instinctive movements also take place. They call for 
food and drink, recognize the objects by which they are surrounded, 
and become fond of cleanliness. They also, in some cases, learn to 
perform simple physical acts, in the same manner as educated animals. 

But their gait always remains unsteady, the expression of the 
countenance silly, and the muscular system weak, while con\^sions, 
and subsequently paralysis, often ensue. These children very seldom 
live past the first and second dentition, and at best attain to no great 
age. 

In the nnldest degree — that of simple mental debility — the small- 
ness of the head is not very striking, the body develops itself, although 
slowly, to its almost normal formation, and one or another sense only 
remains blunted, but asthenopia, or deaf-mutism, also makes these in- 
dividuals useless members of the human family. 

Treatment. — Defective formation of the brain, of course, can never 
be the subject of direct treatment, but, by a proper rearing and edu- 
cation, something may jDossibly be accomphshed in waking up the 
feeble mental powers. Li order to keep such children alive as long 



DISEASES OF THE NERVOUS SYSTEil. 419 

as possible, tlie first requirement is to habituate them to cleanHness, 
without which, ulceration of the skin, quickly followed by atrophy, 
results. 

It is best to remove these children from the paternal home, for the 
long period of time and the rigid surveillance requisite for their im- 
provement are seldom to be found in their own. 

Then it is a question whether it is possible, by incessant, careful 
observation, finally to discover the existence of one or more faculties, 
and to persevere in their progressive cultivation and improvement. 
The main difficulties encountered in this are the indolence and the 
complete abstraction of the idiots. 

The education of these poor creatures requires an almost super- 
human patience — such, indeed, as is very seldom found, their uncleanly 
habits adding much to these difficulties. 

Other diseases of the mind, in young children, are very rare, but, 
after the completion of the second dentition, they are oftener observed. 
Out of one thousand cases of insanity, according to statistical compi- 
lations of cases that have occurred in Bicetre during three years, on 
an average, ten were youthful idiots, epileptics and imbeciles not in- 
cluded. 

From a most careful inspection of these cases, it was found that, 
aside from the hereditary disposition and previous disease, improper 
education and want of care were the chief causes of their condition. 

Le Paulinie)\ the compiler of these statistics, distinguishes three 
forms of mania in the young: (1), maniacal exaltation; (2), insanity; 
and (3), madness. 

In the first form, the faculty of judgment is not completely abol- 
ished ; still, a marked deficiency of reflective faculty exists. The pa- 
tients are talkative, excited, vain ; are a prey to foolish dissipations, 
as well as shameless and violent acts. 

In the second degree, insanity, the confusion of ideas is more pro- 
nounced ; the patient incessantly jumps from one subject to another, 
or from one extreme of feeling to another. In the third and highest 
form, all association of ideas is abolished, and panphobia and mania, 
the signs of commencing paralysis and imbecility, not unfrequently 
become superadded. 

Independent of the real symptoms of mania, psychosis in the youth 
is often complicated mth chorea, or a kind of catalepsy, which comes 
on at uncertain intervals, and in paroxysms of greater or less dura- 
tion. West speaks of children affected with mental diseases, Avho were 
only six or seven years old ; generally, however, the majority of these 
have attained the tenth year, and are approaching pubertv. 

The^ prognosis, in general, is more favorable than in adult dementia. 



420 DISEASES OF CHILDREN. 

but, according to Delasiauve^ there is always a great tendency to re- 
lapses. 

It has been observed that, the longer the stadium of premonition 
lasts, the worse is the prognosis. We are justified in the conclusion 
that, although the cure often appears permanent, a psychical disturb- 
ance occurring in childhood is always to be regarded as a very serious 
disease. 

The treatment in the paternal house is but very seldom effectual, 
and hence it is absolutely necessary to have these patients removed 
to an asylum. 

D.—EIGHEB OBGAM OF SEME. 
I.— Siglit. 

Ophthalmology has gi'own into such a perfect specialty that a gen- 
eral treatise on the diseases of children need not comprise a detailed 
delineation of the diseases of the eye. 

The student may therefore be referred to the works on ophthal- 
mology for information upon this subject, and only the congenital dis- 
eases of the eye, and those that occur in infants especially, will here 
receive a very cursory description. 

(1.) Epicanthus. — By epicanthus is understood an unsightly gath- 
ering of integument in the region of the root of the nose, toward the 
inner angle of the eye, a semilunar fold covering the angle of the eye 
in the form of a pocket. The upper point of this crescent is found at 
the root of the nose ; the lower is lost in the integument of the cheek. 

The root of the nose is always very flat, and the nasal bones meet 
each other at an obtuse angle, so that the folds of the integument, 
elevated by the accumulation of adipose substance, are on a level 
with the depressed nose. 

The pocket never extends so far as to obscure the field of vision, 
but completely covers the inner angle of the eye, and may reach to 
the inner margin of the cornea. 

The cause of this deformity, according to V. Ammo^i^ is a flat 
dorsum of the nose, and a lax adhesion of the integument to the nasal 
and lachrymal bones. This etiology, however, is not very satisfac- 
tory, for there are also children with depressed noses, and easily dis- 
placeable integument, who exhibit no such fold whatever. 

Epicanthus is always congenital and bilateral, but it may be larger 
on one side than upon the other. When the skin on the dorsum of 
the nose is raised up with two fingers into a fold, the deformity dis- 
appears, and this fact suggests the proper operative procedure. As 
the epicanthus is usually seen in the new-born child, and never in the 



DISEASES OF THE NERVOUS SYSTEM. 42I 

adiilt, it follows that, with increasing growth, it must become smaller 
and ultimately disappear. 

This deformity, w^here it does not thus disappear early, may be 
remedied by excising a longitudinal fold of skin from the dorsum of 
the nose, and uniting the edges of the wound by suture. 

(2.) Cyclopia — Monophthalmia. — Total defect of the orbits 
occurs in monstrosities, the frontal bone continues down into the 
upper jaw, and in the bone shallow grooves only exist in place of the 
orbit. In defective formation of the brain (hemicephalia), the bones 
of the orbit are only rudimentarily formed, and its upper border, in 
particular, is very much diminished, and very close to the optic fora- 
men. 

Cyclopia finally is likewise only possible in defective orbital bones. 
Here the ethmoid, the lachrymal, and the nasal bones are absent, and 
the sphenoid bone is also altered in shape. These are mere malfor- 
mations, met with only in monstrosities incapable of living, and are, 
clinically, of no interest. 

(3.) Malfoemations or the Eyeball. — (a.) Colohoma iridis s. 
iridoschisma^ a congenital splitting of the iris, is a condition similar 
to that of harelip ; the fissure in most cases runs downward, and the 
deformity is more frequently seen in both eyes than in one only. Its 
edges converge toward the ciliary border, and are but seldom parallel 
or diverging, so that the pupil mostly assumes the form of a pear, 
with the base directed downward. In rare instances a fissure in the 
large circle of the iris alone is observed, so that a normally round 
pupil, with a peripheral, triangular opening, separated from the pupil 
by an iris-colored transverse band, is present. By the alternate pres- 
ence and absence of light in front of a coloboma, its margins may be 
seen to shorten and elongate like the contractions and dilatations 
of the pupil, but this closure never is great even under the influence 
of a strong hght. 

This condition has often been observed as an hereditary one. The 
complications occurring with it are : microphthalmus_^ ovale corne^e, 
central lenticular cataract, harelip, hypospadias, cerebral defects, and 
coloboma of the upper eyelids. 

The latter is only observed on the upper eyelid, and consists in a 
narrow fissure of the tarsal cartilage, in which the external integument 
is not correspondingly fissured. 

There is no embryological explanation for this malformation, such, 
for instance, as is readily found for harelip, for the upper eyelid at 
no time of embryonic life consists of two parts. 

(b.) Irideremia. — Total or partial congenital absence of the iris 
is always observed simultaneously on both sides, a single instance 



422 DISEASES OF CHILDREN. 

reported bj 3Iorison, excepted. Either no iris, or but a rudimentary 
strip onlj, is seen. 

Here tlie pupil properly never presents the background of the 
healthy eye. In certain positions, with reference to the Hght, they 
glisten like the eyes of cats. This also happens occasionally in large 
colobomas. Usually the cornea is not normal, it is oblong, or gradu- 
ally merges into the sclera, and the lens may likeiyise be opaque. 

Such children naturally are always short-sighted, and, on account 
of the too great amount of light admitted, constantly contract their 
eyelids, by which means they obtain a sort of substitute for the de- 
ficiency of the pupils. 

A constant rolling of the balls (nystagmus oscillatorius and rota- 
torius), on account of this incompleteness of the power of vision, also 
becomes superadded. This malformation, according to Arlt, has never 
led to blindness by paralysis of the retina, but inflammation of the 
cornea and conjunctiva, and also gTadual lenticular opacity, very fre- 
quently ensue. 

The treatment must be confined to efforts to control the amount 
of light admitted to the eye, by the use of blue glasses or artificial 
diaphragms. 

(3.) Sard Cataract. — Cataracta nuclearis is a sharply-defined, 
grayish-white point, of the size of a poppy-seed, in the centre of the 
lens, around which a brighter zone is sometimes observed. It is 
mostly met with in both eyes, and is often complicated with absence 
of the iris or coloboma. 

In addition, white points also develop themselves in children after 
birth, in the lens or its capsule, and send out white radiating stripes, 
thereby obscuring the vision, but not entirely destroying it, as the 
opacity of the lens never becomes general. 

(d.) Atresia 2yu2nllaris congenita. — Congenital closure of the pupil 
is due to an anomalous continuance of the pupiUary membrane after 
birth. 

According to ^ischoff^ the membrana-capsulo-pupillaris, and the 
membrana pupillaris together, form a vasculo-membranous sac, which, 
issuing from the posterior circumference of the lenticular capsule, 
extends through the posterior chamber of the eye as far as the iris ; 
here it is connected with the iris by vessels, and by its anterior wall 
represents the membrana pupillaris. 

But this sac originally seems to envelop the lens and its capsule 
only, for the lens at an early period Hes closely behind the cornea, 
and no iris as yet is present. But, when the iris begins to develop 
itself, it becomes united to the anterior part of this sac, holds the 
united membrane back as the lens recedes after the formation of the 



DISEASES OF THE XERYOUS SYSTEM. 423 

anterior cliamber of the eye, and thus a true membrane originates 
before the pupil, the membrana pupillaris. 

This membrane, it is said, begins to disappear from the seventh 
month, and should be wholly gone at birth, but often it remains as a 
transparent membrane, with few or no vessels, for a long time yet 
after birth. 

There are a number of cases in which, according to Stellwag von 
Carion, the pupillary membrane has been seen in its integrity in new- 
born children, and even in adults. It is seen as a fine, grayish-white 
membrane, accurately expanded on a level with the pupil, closing it, 
thereby destroying the power of sight to some extent, and making 
the iris immovable. In some instances this membrane is perforated, 
or a few shreds only hang on the pupillary borders. Stellwag warns 
us against the possibiUty of confounding this condition w^ith organized 
exudation and capsular cataract, and considers the prognosis of con- 
genital closure of the pupil as favorable. Nature, in time, makes 
amends for what it was remiss in at birth. The action of the iris 
muscle lacerates the membrane, and the torn fragments are gradually 
absorbed. 

The evil, on the whole, is very rare, and many busy oculists have 
never met with it. 

So much in regard to congenital malformation of the eye. The 
period of infancy is decidedly predisposed to diseases of the eye, and 
we should have to compile a complete treatise on ophthalmology if all 
the morbid conditions occurring in it were here to be described. 

Two affections of the eye, specially belonging to children, blennor- 
rhoea of the new-bom child, and oedematous conjunctivitis during den- 
tition, have already been minutely treated of in their appropriate chap- 
ters, pages 73 and 110. Scrofulous affections of the eye in children 
will be described in a future chapter on scrofula. 

The other diseases of the eye differ little in any respect from 
those that occur in the adult, and consequently may be properly 
omitted here. 

It should be observed that, in children, the outer structures gen- 
erally, and especially the conjunctiva, the lids, and muscular appara- 
tus, become diseased, while adults more frequently suffer from morbid 
alterations of the inner parts of the eye, the iris, lens, vitreous hu- 
mor, choroid, and retina. 

II,— Hearing. 

I. — Malfoemation of the Orgajst of Heaeijs'g. — (a.) Absence 
of the Auricles (Ears), Defectus Auriculce. — Occasionally an abnor- 
mal congenital smallness, shrinking, or a complete absence of the 



424 DISEASES OF CHILDREN. 

auricle, upon one or both sides, occurs, and is usually complicated 
with malformations of other organs. 

Aside from the very striking deformity, this defect also causes a 
detriment to the hearing, although it is but a slight one. 

If any treatment to mask the deformity is to be instituted, the 
first measure should be properly shaping the hair so as to cover the 
ear. If for any reason this be not available, there will be no other 
resource than to wear artificial ears. Artificial ears are made either 
from papier-mache, pressed leather, or cast metal, painted in oil-col- 
ors, and attached to the rudimentary auricles by the aid of a clamp, 
or, when no point of attachment at all exists, by a spring, passing 
over the top of the head, which is hidden by the hair. This, naturally, 
is only applicable to older and controllable children. Otoplastic sur- 
gery, the formation of ears from adjacent integuments, has never, ac- 
cording to Rau^ succeeded in producing a structure at all resembling 
auricles, and hence, on account of the painfulness of the operation, 
and the impossibility of preventing cicatrices, should be abandoned 
entirely. 

Aside from the absence of the auricle, a faulty position of this 
structure is also met with. It either lies very close against the 
cranial bones, auricula adpressa^ or it stands ofi" at a right angle from 
the skull. 

The first deformity rarely calls for any surgical interference, al- 
though the fineness of hearing is somewhat weakened, but in the 
latter we are often applied to for the purpose of improving the ap- 
pearance. In new-born children very prominent ears may readily be 
brought into a proper permanent position by means of strips of ad- 
hesive plaster which are applied for several weeks. A child was 
once brought to me with one auricle perfectly normal, while the other 
was bent forward or rather deflected to such a degree that its poste- 
rior surface only was seen, completely covering the meatus. 

Even this marked deformity was permanently relieved by the ap- 
plication of strips of adhesive plaster for several weeks. 

(b.) Closure of the Meatus Auditorius, Atresia, sive Ohliteratio, 
sive Imperforatio Meatus Auditorii. — It sometimes certainly hap- 
pens that the osseous canal, in consequence of abnormalities in the 
bones, is entirely absent ; generally, however, it is normally present, 
and its mouth is only closed by a membrane. 

With this condition, a defect or deformity of the auricle becomes 
associated as a complication. 

The aperture of the canal is either indicated by a small depres- 
sion, or the closing membrane is so smoothly expanded over it that 
the bony orifice cannot be detected with certainty either by the touch 



DISEASES OF THE NERVOUS SYSTEil. 425 

or sight. This pseudo-membrane is seldom seen to dip so far inward 
as to represent the canal as a short cul-de-sac. 

This membrane is distinguished from the membrana tympani by 
its superficial position, and by its insensibility when touched with 
the probe. 

The hearing is almost entirely abolished by this condition ; fortu- 
nately, however, the malformation occurs only in one ear. This 
membranous closure must also be distinguished from mechanical 
occlusion of the meatus by vernix caseosa, or, in older children, by 
filth and foreign bodies of all kinds. 

The occlusion of the ear often remains undetected for a long time 
when the auricle is well formed, and is discovered by the children 
themselves in the coiu-se of years, and as they gain in observation. 

Treatment. — This defect can only be reheved by an operation. 
This consists in making a crucial incision into the membrane, which 
is expanded over the orifice ; the flaps are seized by a fine, hooked 
forceps, and are snipped ofi" with a curved scissors. 

The after-treatment is the most difficult part of the operation, for 
there is always a great tendency to reclosure, which must be over- 
come by the introduction of pledgets of lint, sponge-tents, and sub- 
sequentl}^ a silver tube. 

The meatus, notwithstanding all this, sometimes closes again after 
many months. 

In bony occlusion, which scarcely ever occurs without other re- 
mote malformations, hemicephalia, etc., nothing of course is to be 
hoped for from an operation. 

(2.) Simple Inplajmmatiox of the Meatus Auditorius {Otitis 
Externa). — We omit the inflammations and other alterations of the 
auricle, which, like any other part of the corporeal surface, may be at- 
tacked by various cutaneous diseases, and apply ourselves directly to 
otitis externa^ acuta, et chronica. 

Symptoms. — The meatus represents a cul-de-sac, the bottom of 
which is formed by the membrana tympani. Its anterior jDart is pro- 
vided with sebaceous glands, its posterior, corresponding to the bony 
canal, with ceruminous glands. Although its lining membrane, as far 
as the sebaceous glands extend, is analogous to the external integu- 
ments, still the characters of the membrane lining the osseous canal 
are altogether difi'erent. 

The denomination mucous membrane is not at all appropriate, for, 
in the physiological state, it is arranged for the secretion of the ceru- 
men, which has not the least resemblance to mucus. 

In the inflammatory processes the secretion certainly becomes 
muco-purulent, and, with the exception of its smell, is not distinguish- 



426 DISEASES OF CHILDREN. 

able from that of an ozoena, and then it may indeed be assumed that 
the membrane so diseased has assumed the properties of a mucous 
membrane. When this metamorphosis takes place, the ceruminous 
glands cease to perform their function ; the reappearance of this cerumen 
may therefore be looked upon as a sign of commencing improvement. 

In the inflammation of the meatus we may distinguish an erythem- 
atous and a catarrhal form. 

In erythematous otitis, the meatus, when closely examined by the 
aid of the speculum, is seen to be reddened, and a brownish cerumen, 
somewhat increased in quantity, is found. After several days, the 
whole meatus desquamates in large or small scales, the large quantity 
of cerumen dries into a crumbling crust, which falls out when the 
patient lies on the affected side, or is washed out by injections. 
This very frequent disease is almost painless ; the auricle may be 
pressed and pulled in every direction, without causing any pain. The 
general state of the system remains undisturbed, and, in children, its 
presence is usually accidentally detected in the examination for other 
diseases. 

Catarrhal otitis produces more significant local and general symp- 
toms than the erythematous. 

The invasion of the disease is attended first by an itching, then by 
actual pains, which, without any other alterations, may last for several 
.days, when a yellowish-white, purely fluid or flocculent fluid discharge 
appears. This, at first, is nearly odorless, but at a later date assumes 
an intensely sour odor, or like that of rancid fat. The discharge is 
not always equally profuse, and its quantity is best estimated by the 
stains which are found in the morning on the child's pillow. 

In a profuse otorrhoea, these stains cover the pillow with patches 
the size of half of the palm of the hand. After a few days or weeks 
the discharge in the simple otitis externa ceases ; it becomes cheesy, 
and the ceruminous secretion reappears. The deafness that existed 
during the otorrhcea also passes off. Generally, the secretion poured 
out dries in part in the auricle, and by the irritation it causes produces 
erosions and superficial ulcers, which extend to the lobe and adjacent 
parts, and are much disposed to bleed. At the same time the mem- 
brane lining the meatus swells up to such a degree that the walls al- 
most touch each other, so that the tympanum cannot be seen, not 
even after a thorough cleansing, nor by the aid of the best Kght. 

The examination with the speculum is exceedingly painful, and 
when attempted produces haemorrhage, which still more obscures the 
parts and counteracts the little benefit that might otherwise be de- 
rived from it, and therefore may be entirely omitted. 

In cachectic, and especially in scrofulous children, otorrhoea easily 



DISEASES OF THE NERVOUS SYSTEM. 427 

becomes chronic. It is often absent for montlis in tbe warm season 
of the year, and returns in winter with renewed severity. 

Sometimes the secretion is a glairy mucus, sometimes again puru- 
lent, and usually erodes the lobe of the ear. The mucous membrane is 
less infiltrated than in the acute form, but, w^hen the disease has ex- 
isted for a long time, polypoid excrescences will form upon it, causing 
a decided aggravation of the deafness. 

A chronic otorrhoea can never be regarded as cured, even when 
the discharge has stopped completely, so long as no cerumen, but a 
cheesy, smeary, fetid mass is found deep in the ear. This is always 
proof that the membrane has not yet assumed its normal function, and 
that the purulent secretion is but temporarily suspended. So long as 
the cerumen is not found in considerable quantities, no complete re- 
covery can be assumed to have taken place. Chronic otorrhoea seldom 
attacks both ears at the same time, and with the same degree of se- 
verity, but an alternating condition usually takes place. 

The prognosis depends upon the state of the membrane lining the 
meatus, and upon the constitution of the child. The degree of the 
swelling of the membrane and of the excoriation, the amount of granu- 
lations, the presence of polypoid growths, are all points which enter 
into the prognosis, which must be favorable or otherwise according to 
the degree and extent of these complications. In scrofulous children 
it is likewise very difficult to effect a cure, and the disease returns 
after every exposure to cold and after every indisposition. 

According to Hau and Wilde, the much-dreaded results, perfora- 
tion of the tympanum, secondary periostitis, and diseases of the brain, 
never occur as effects of simple external catarrhal otitis. This view is 
said to have originated from inaccurate diagnosis, which is certainly 
by no means inexcusable, from the fact that, notwithstanding repeated 
injections, the meatus cannot be properly inspected for many weeks, 
particularly if the swelling be at all severe. 

Etiology. — There is an intimate connection, in many children, be- 
tween affections of the mouth and of the ear, as may, in fact, be read- 
ily divined from the anatomical contiguity of the parts. 

Thus there are certain children who, at the cutting of every tooth in 
the first as w^ell as in the second dentition, are attacked by otalgia and 
an otorrhoea, of a longer or shorter duration. This affection occurs as 
a sequela of scarlatina and measles extremely often, and is associated 
with scrofulous eruptions of the head, which extend into the meatus. 
Generally, the otorrhoea in young atrophic infants is not the simple 
external form, but the inflammation extends to the middle ear, and 
will hereafter be described. 

Therapeutics. — Simple external otitis terminates favorably even 



428 DISEASES OF CHILDREX. 

•without any treatment, and there is therefore no necessity to torture 
the patient with the vesicants and pustulating ointments so much in 
TOgue, by which an adchtional disease is produced without paUiating the 
original one. At first, two or three injections of tepid water, daily, 
and stuffing the ear with charj^ie, is all that is requisite. If the pain 
is intense, causing sleeplessness, one to four drops of laudanum, ac- 
cording to the age of the child, may be given in the evening. Astrin- 
gent injections in the first days of the discharge are totally useless, and 
in most instances they cause intense pains and an augmentation of 
the discharge, on account of which it is best to confine the treatment 
for the first eight days to injections of simple warm water. Of all the 
astringents, I consider a solution of alum ( 3 j to water | j) the best 
and simplest, a few drops of which are dropped into the ear morning 
and evening, after the ear has been syringed with warm water and 
wiped dry. This solution is as efficacious an astringent as nitrate of 
silver, and has the important advantage that it neither stains the linen 
nor discolors the skin. After several weeks the discharge ceases entirely. 
If no cerumen appears, a few drops of cod-liver oil with iodine (gr. j to 
3 j) should be dropped into the ear. This will cause some itching for 
a time, and will be followed by a return of the normal secretion. In 
scrofulous children, a general treatment with cod-liver oil, iron, baths, 
gymnastics, etc., may always be instituted with advantage, as will be 
more minutely discussed in the chapter on scrofula. 

(3.) Abscesses r^r the Meatus {Otitis Externa Fhleg mono so). — 
The symptoms of phlegmonous otitis, with suppuration, are much more 
\nolent than those of the pre\dous form. Abscesses can only occur in 
the anterior and easily-accessible parts ; for only this, the cartilagi- 
nous portion, contains a layer of cellular tissue, while, in the osseous, 
the periosteum and lining membrane are intimately united. The pain, 
at first, is bearable, and nothing but a general redness and slight tume- 
faction are observed ; but, after twenty-four to forty-eight hours, the 
pain becomes aggravated to an excruciating intensity ; the child cries 
night and day without ceasing, is unable to sleep, and every motion 
of the lower jaw increases the pain. On this account these patients 
speak indistinctly, and swallow with the utmost caution. Even young 
infants, but a few months old, are liable to be attacked by this affec- 
tion, and indicate to their attendants the site of the disease by fre- 
quently pulling at the ear. After these pains have continued for two or 
three days with uniform severity, they then become throbbing, and can 
only be alleviated by comparatively large doses of morphine. The 
meatus, in the mean time, has become completely closed by swelling, 
and, if examined Tvnth a probe, it will be found that the swelling is not 
uniform, but that one part of the meatus, generally the lower, is ele- 



DISEASES OF THE NERVOUS SYSTEM. 429 

vai^d into a small fluctuating abscess of the size of a pea. A few 
drops of pus and blood escape when this abscess is opened, or when it 
bursts spontaneously, and the pain then instantly subsides, but the 
little abscess still suppurates for a few days, then becomes completely 
closed, the adjacent redness and swelling also decline, and the whole 
disease in a few days entirely disappears, leaving scarcely a trace be- 
hind. 

I am not aware of any positively certain cause for it. Abscesses 
of the ear occur as well in healthy as in scrofulous children, but are 
especially frequent in children who are teething. The prognosis is 
extremely favorable, a fact that does not always seem probable to the 
less experienced, on account of the violent symptoms which usher in 
the affection. Induration or ulceration, with exfoliation of the carti- 
lage and bones, scarcely ever ensues. Periostitis of the external meatus 
is very rare in young children ; on the other hand, however, there are 
several diseases following, and frequently due to periostitis of the 
middle ear. 

Therapeutics. — The principal object is the speedy mitigation of the 
extremely torturing pains, which may be accomplished by a cautious 
admmistration of opium or morphine, they being the most efficient 
remedies. It is also very important that the patients should use a 
firm horse-hair pillow, by means of which the internal ear is less liable 
to be compressed. Topically, it is best to inject warm water, and con- 
duct the steam from hot chamomile-tea upon the abscess. The appli- 
cation of poultices invariably causes pain, and they do not perceptibly 
promote suppuration. The only means by which we can afford the 
patient immediate relief is to open the abscess as early as possible, 
for which a simple incision suffices. The injections of tepid w^ater 
should then be continued for a few days, when the w^hole difficulty 
will entirely disappear. 

(4.) IxFLAioiATiox OF THE MiDDLE Eae {OtUis Interna). — In 
inflammation of the middle ear, either that of the mucous membrane 
alone, or, conjointly with it, of the periosteum and bone, may occur, 
and, for this reason, we have to discriminate between (1) a catarrhus 
and (2) a periostitis auris mediae. 

(a.) Catarrhus Auris Medim. — This disease must be regarded as 
the most frequent cause of the deafness wliich attends inflammation 
of the ear, and because it usually occurs in both ears at the same time. 
The catarrh is probably propagated from the Eustachian tube to the 
tympanum, and the mucous membrane of the tympanum, when once 
inflamed, behaves like other chronically-affected mucous membranes. 
Hence we see improvement, soon followed by exacerbations. These 
children suffer most from deafness in damp weather, or when aftected 



430 DISEASES OF CHILDREN. 

with cold. After hawking, sneezing, or vomiting, tolerably good li#ar- 
ing suddenly ensues, but, after a few hours, again disappears. 

The diagnosis of catarrh of the tympanum in children cannot be 
as accurately made out as in adults, for the former do not willingly 
submit to have the Eustachian tube explored. Hence the air-douche, 
the chief diagnostic test in the disease, cannot be obtained. The in- 
spection of the external meatus, by the aid of a speculum, furnishes 
negative results, as nothing abnormal can be discovered by it, nor do 
the feeble changes in the color of the tympanum, upon which some 
aurists place great value, supply any sufficient diagnostic information. 
In fact, the principal symptom is a deafness or hardness of hearing, 
changeable with the weather, and combined with catarrh of the mouth 
and nose, and a negative state of the external meatus. 

The termination is usually a sad one, as good hesiring seldom re- 
turns in any case of chronic catarrh of the middle ear. The patients, 
therefore, should be content, if the disease do not become more and 
more aggravated, and terminate in total deafness. In most instances, 
the cause is inherited scrofulous cachexia, which, in these children, 
predisposes to hardness of hearing, and is much less liable to become 
localized upon other parts, such as the eyes, nose, and skin. 

Treatment. — The local treatment should be restricted to the ex- 
tirpation of the hypertrophied tonsils, abscission of the elongated uvula, 
and inflations of powdered alum into the fauces, because, as has been 
already stated, in children, the catheterism of the Eustachian tube and 
the air-douche can seldom readily be applied. I have treated three 
cases by keeping up a constant pustular eruption alternately behind 
the ears and on different parts of the neck, with very good results. I 
have been led to adopt this treatment from the fact that most of these 
children, suffering from partial deafness, are more or less scrofulous ; 
and I have also repeatedly observed that they are but seldom, and in 
a very slight degree, troubled with cutaneous eruptions, and derive 
benefit from this treatment. Two of the cases above referred to, as 
treated in this manner, recovered their previous good hearing almost 
perfectly, and, although the third is not much improved, stiU the symp- 
toms exhibit no special aggravations. I am in the habit of employing : 

5. Empltr. adhsesiv. flav., 3iv, 
Tartar, stibiat. . . . 3j, 

which is smeared upon a piece of linen, of the size of a silver dollar, 
and allowed to lie upon the skin for four days, when the spot will be 
found to be covered with bloody pustules, which are not disposed to 
heal, but will suppurate for many days. As soon, however, as these 
have healed, the samx process may be repeated on another place. 



DISEASES OF THE NERVOUS SYSTEM. 43I 

These cMldren should also be guarded against catarrhs, which is 
best accomjDlished by inuring them to the changes of the temperature 
by the daily cold bath and country air. A general treatment, %vith 
iron and cod-liver oil, is also indicated by the scrofulous complication. 

(b.) Inflammation of the Periosteum of the 3fiddle Ear — Peri- 
ostitis — the Real Otitis Interna. — Periostitis of the middle ear is the 
most important and dangerous of all the diseases of the ear, for it not 
only produces the most intense pains, and most frequently leads to 
total deafness, but life is also endangered by purulent meningitis of 
the most intense form, which is apt to supervene. For that reason, 
also, has it attracted the universal attention of aurists, and its symp- 
toms and terminations are much more minutely described than any 
other disease of the ear. 

Symptoms. — In ciiildren the disease almost always begins sud- 
denly, and, fortunately, attacks but one ear, never both at the same 
time. A rapidly-increasing, boring, lancinating pain comes on in the 
affected ear, which radiates over the adjacent parts, the temple, back 
of the head, neck, and jaws, and, in a very short time, becomes so in- 
tense as to almost drive the child to distraction. It screams and 
cries incessantly, and cannot be tranquillized in any manner. Toward 
evening the pains reach their utmost intensity ; they are also aggra- 
vated by all movements of the lower jaw, and of the head generally, 
by swallowing, sneezing, coughing, and particularly by loud noises. 
Nevertheless, the increased irritability of the nerve of hearing, which 
manifests itself by greater sensibility to noise, and by constant buzzing 
in the ears, subsides very soon, and is succeeded by more or less com- 
plete, deafness. These violent local symptoms, as might be supposed, 
are not unattended by reflex action upon the general system. Violent 
fever, very frequent and hard pulse, general malaise^ cold sweats, and 
great thirst supervene. 

In nurslings, all the symptoms just enumerated cannot always be 
elicited. They are extremely restless, cry at every noise that is made, 
frequently pull at their ears, and, when at last they have fallen asleep, 
will wake at the slightest noise with a cry of pain, and incessantly 
rub the head to and fro upon the pillow. Pressure upon the affected 
ear also gives rise to the loudest outcries of pain. When put to the 
breast, they will suck at it only for a short time, arid break off wdth a 
cry, because the act of sucking aggravates the pain, and, on the other 
hand, drinks administered by a spoon are swallowed with avidity-. 
Like all other pains and febrile diseases, so is also this condition 
capable of causing partial or general convulsions, and then it is very 
Hable to be confounded with other cerebral affections. 

The examination of the external ear in the first days of the disease 



432 DISEASES OF CHILDREN. 

furnishes no positive results, and, besides, is extremely painful, par- 
ticularly when the speculum is used. 

These painful phenomena never last longer than five, or at the ut- 
most six days. But, before the expiration of this time, death, in ex- 
ceptional cases, may take place by convulsions, or under meningitic 
phenomena. An actual simple resolution of the inflammation, attended 
by a subsidence of the pains, may indeed also occur, but in this case 
there is always a suspicion of a diagnostic error. In most instances, 
the inflammatory pus and the deposited purulent exudation tunnel 
a passage outwardly in various directions. 

The most frequent termination is by perforation of the tympanum, 
followed by discharge of bloody-streaked, highly-pungent pus. The 
small bones of the ear, and some pieces of necrosed bone, may escape, 
followed finally by the cure of the periostitis, with complete deaf- 
ness of the afibcted side. Still, it also happens that the small bones 
of the ear are not discharged, that the perforated tympanum, after the 
pus escapes, closes up again, and then a slight hardness of hearing 
only remains. 

Some solitary cases are recorded where the pus escaped through 
the Eustachian tube. They seem, however, to occur but very rarely, 
and cannot be demonstrated in children, who swallow the pus, not un- 
derstanding how to remove it by hawking. 

Another way in which the pus frequently escapes is into the cells 
of the mastoid process. An oedematous redness is then observed be- 
hind the auricle, the red spot bulges up more and more, fluctuates 
distinctly, and ultimately, if left to itself, will open. The copious 
bloody pus which escapes at first likewise has a jDungent odor, and car- 
ries off with it some particles of bone, and, after a few weeks, becomes 
mucous and shreddy. If the abscess is explored with a probe, a few 
exjDosed sjDots of rough, denuded bone will almost always be detected ; 
sometimes, however, this is impossible, owing to the curved or angu- 
lar course of the cavity. The pus is so rich in sulphuretted hydrogen 
and sulphuret of ammonia, that the silver probe quickly becomes dis- 
colored. Ultimately, the fistulous track closes, but not till after many 
months, and even years, and the contracted cutaneous cicatrix remains 
consolidated with the bones. Deafness is the most usual termination, 
and, in the rarer favorable instances, deafness of a lesser degree simply 
results. When the caries extends to the Fallopian canal, convulsions 
will take place, and subsequently paralysis of the facial nerve, which 
runs through this passage. This paralysis is not permanent in all 
cases ; it may disappear again soon after the pus that has exercised 
the pressure escapes, but, when it has lasted for several months, as a 
rule, it will be permanent.. 



DISEASES OF THE NERVOUS SYSTEM. 433 

The ^YO^st event to be dreaded here is the involvement of the 
labyrinth, and necrosis of the petrous portion of the temporal bone, 
with consecutive purulent meningitis and encephalitis. The purulent 
collections in the brain usually communicate with those in the internal 
ear, and, when the tympanum becomes perforated, may even escape 
outwardly. But abscesses also occur in the brain without the petrous 
bone being markedly affected, thus proving that otitis interna, aside 
from producing a direct mechanical propagation, is also capable of 
bringing about a concentric cerebritis. These cerebral complications 
invariably terminate fatally. 

Prognostically, the perforation of the tympanum, with discharge 
of the matter outwardly, when the extremely doubtful resolution is 
excluded, may be looked upon as a favorable termination, especially 
if the rare and fortunate event occur of the bones of the internal ear 
being retained, and the tympanum closing up again. 

Much less hopeful and promising is the result in caries of the mas- 
toid process, whereby the deafness usually becomes more marked, the 
fistulse remain open for years, and painful contracting cicatrices form. 
In caries of the petrous portion of the temporal bone, which manifests 
itself by gTave meningitic symptoms, by unilateral convulsions, and, 
subsequently, paralysis, the prognosis may generally be regarded as 
fatal. In general, it may be assumed that the children who suffer 
from otitis interna are scrofulous to a high degTee, and that, therefore, 
tuberculosis of the lung mil, with great probability, ensue after the 
appearance of puberty. 

Etiology. — Scrofulosis and tuberculosis furnish the chief predis- 
posing causes of this affection. It either alternates with scrofulous 
exanthemata, the disease localizing itself, immediately after their rapid 
desiccation, in the internal ear, without any simultaneous external 
otorrhoea, or a similarly scrofulous purulent discharge from the meatus 
auditorius finally causes perforation of the tympanum, and thus gains 
entrance into the middle ear. This affection also supervenes upon an 
acute exanthema, and particularly scarlatina. The exciting causes 
deserving to be mentioned are, foreign bodies in the external ear, 
those that irritate the tympanum, such as chemical corrosive liquids, 
which intentionally, with criminal intent, or accidentally, have been 
poured into the ear, and, lastly, violent injuries and blows in the 
region of the ear. 

Treatment. — The extraordinary severity of the pain at the com- 
mencement of the disease induces the relations of the child to covet 
as speedy a relief as possible, which, however, cannot be satisfied in 
most instances as rapidly as is desired. The most effectual of all 
pain-assuaging remedies, opium, ought not to be given to infimts, 
28 



434 DISEASES OF CHILDREX. 

especially to those who have not passed the first dentition, because 
sopor, followed by cerebral irritation, may be produced, and thus the 
efi"ects of the opium, and the morbid process which is being propagated 
to the brain, will not be distinguishable. Cautious experiments with , 
opium may, it is true, be instituted, even in young children, for these 
dreadful consecutive effects do not ensue in all cases ; but we have to 
limit ourselves to such small doses, that the desired pain-assuaging 
effects have not usually been realized. 

Much better effects have been obtained, in young children, from 
bitter-almond water and extract of belladonna. Topical abstraction 
of blood, whose pain-alleviating effects certainly cannot be denied, 
should be very sparingly practised, as almost all children affected by 
this disease are scrofulous, and have already been sufficiently reduced 
by the pain and fever attending it. 

Leeches should never be applied in greater numbers than the num- 
ber of years of the child's age. General abstraction of blood should 
be avoided entirely. 

Most children tolerate nothing in the external meatus nor upon 
the auricle, and the pain is best borne when the ear is entirely free, 
and not in contact with any thing. If, in a few days, the pains become 
throbbing, and the parts in the vicinity of the mastoid process red- 
dened, warm vapors of chamomile-tea may be advantageously con- 
ducted into the meatus, and the parts behind the ear may be poul- 
ticed. As soon as the pus bursts through the tympanum, or exter- 
nally through the mastoid process, all pain suddenly ceases, and it is 
now principally a question of properly keeping up the discharge. For 
this purpose it is absolutely necessary to provide the relatives with a 
good metallic (not glass) s^Tinge, and to instruct them thoroughly in 
its use. Injections of warm water, regularly repeated every two or 
three hours, afford the only guarantee that the matter escapes without 
pain and without interruption. The meatus should never be wiped 
out with the twisted corner of a jDocket-handkerchief, for the greatest 
amount of irritation is produced by the practice, and it should be en- 
tirely discarded. But, if it is totally impossible to remove the secre- 
tion, crusts will form, especially on the mastoid jDrocess ; the jdus is 
then prevented from escaping, and increased pain will be the result. 
In this case, the use of sweet-oil may be of some benefit. If the in- 
flammatory stadium has already expired, astringent injections may be 
commenced, and a solution of alum ( 3 j to water | j) will be found 
to answer the purpose best. In caries of the mastoid process. Ban 
recommends a solution of sulphate of copper (gT. ii — xii to water 3 j) 
to be injected into the cancelli of the bone. 

Internally, during the inflammatory stage, up to the bursting of 



DISEASES OF THE NERYOUS SYSTEM. 435 

the abscess, small doses of calomel are generally given, by which the 
bowels are kept open, and the intensity of fever diminished. The 
termination in suppuration, however, is not by any means prevented 
by it. The children subsequently require a tonic and anti-scrofulous 
treatment, with cod-liver oil, iron, cinchona, ale, wine, meat diet, sea- 
baths, and country air, etc. 

Referring the student, for descriptions of the rarer forms of inflam- 
mation of the internal ear, and of otalgia and nervous deafness, to the 
special works of Man, Kramer, and JErhardt, we will now proceed 
to make a few remarks upon — 

(5.) FoEEiGX Bodies ii^- the Eae. — There is a great natural pro- 
pensity in the child — ^proceeding, perhaps, from curiosity — to perform 
various experiments on its body, and to examine more minutely the 
ca^dties which open upon its surface. Hence the particular dispo- 
sition to push small objects into the apertures, and then to await their 
eff"ects. In most instances the objects pushed into the meatus are 
readily recognized when a ray of sunlight is allowed to fall upon 
them ; but, when tumefaction, as a result of irritation, has already 
supervened, the examination will be much more difficult. Probes 
should only be used with the utmost caution, for with them the extra- 
neous bodies are readily thrust still farther in. 

The symptoms which are induced by a foreign body in the ear 
vary very much according to its nature and form. Smooth, round ob- 
jects, which do not swell up in the ear, often produce no symptoms at 
all for a long time, but, when rough, long, or swollen, the meatus al- 
ways suffers, and painful otorrhoea ensues. The tympanum is liable 
to be perforated by the otorrhoea, and in particular by the unsuccess- 
ful attempts at extraction, and all the symptoms of otitis interna, de- 
scribed in the preceding section, are renewed. The objects most fre- 
quently introduced are : cherry-stones, grape-seeds, peas, beans, len- 
tils, pebbles, glass beads, balls of paper, and pieces of confectionary. 
The lumps of indurated cerumen, cotton, wool, and filth, and con- 
cretions, the so-called otolithes, so frequently met with in aged people, 
are scarcely ever observed in children. Living animalcula, it is true, at 
first produce very unpleasant sensations ; soon, however, they adhere 
to the cerumen, and perish quickly, or may be killed by a few drops 
of water or diluted spirits of wine. The ear- worm (forficula auricula), 
so much dreaded by people, occasions no special danger, but behaves 
in the ear in as harmless a manner as all other living animalcula of 
that calibre. 

The most serious symptoms are those occasioned by corrosive sub- 
stances, nitrate of silver, caustic potassa, and the mineral acids, by 
which the tympanum is destroyed in a very short time, and the whole 



436 DISEASES OF CHILDREN. 

train of terrible symptoms of otitis interna is set going. Of all tlie 
extraneous non-corrosive substances, those of an organic character are 
the worst ; the moisture and warmth of the meatus cause them to 
swell up ; this is especially applicable to peas, beans, and lentils ; in a 
lesser degree also to all fruit-kernels. Small pebbles and glass beads 
are tolerated for a long time without any serious effects, if they have 
not been too firmly wedged in by forcible attempts at extraction. The 
condition is most favorable in confectionary articles ; they soon soften 
and liquefy, a result much accelerated by a few drops of water. 

Treatment. — The only and chief indication, the removal of the 
foreign body, cannot always be quickly enough carried out, for the 
tumefaction of the meatus and pain often render this impossible. 
Tliese symptoms should first be palHated by leeches, cataplasms, drop- 
ping in of oil, and injections with warm water. There are various 
methods of removing the foreign substance, some of which, however, 
are laborious and adventurous. The forcible injection of a stream of 
tepid water is undoubtedly the safest and simplest means of setting it 
afloat. It is hardly ever of precisely the same form as the meatus ; 
the water, therefore, gets behind it, and gradually sets it afloat, and 
it soon after makes its appearance at the verge of the meatus, and 
can thence easily be picked out. If this measure has failed to re- 
move it, we may resort to elevators. These may be made at any 
time, by bending the blunt end of a fine hair-pin toward the flat sur- 
face. The end, thus curved, is carefully insinuated behind the foreign 
body, which is easily brought out. In desperate cases, small blunt 
hooks may also be resorted to ; these should be introduced flat-wise, 
and then turned so as to come against the object from behind. Tlie 
utmost caution, however, should be exercised in their use, for the 
points of the hook may break off, and, if the patient is at all restless, 
the tympanum is liable to be ruptured. Forceps, if the bodies are 
round, such as peas, beans, pebbles, beads, etc., are totally useless and 
even injurious, for two branches require more space than the foreign 
body, in order to embrace it at its largest diameter, and therefore 
rarely grasp it. They almost always slip off, and thereby push the 
article still farther inward. 

A third method, which, to be sure, is very mild, as well as often 
ineffectual, consists in extraction by the aid of some teoacious sub- 
stance which has previously been brought in connection with the ex- 
traneous substance. For this purpose, a quiU, cut off smooth at both 
ends, is introduced into the ear, and through this a piece of tape 
soaked in glue pushed down upon the foreign body. After a few hours 
the tape ^Yil\ be found to adhere pretty firmly to the article, and then 
it is sometimes very successfully and agreeably pulled out. But, when 



DISEASES OF THE GENITO-URINARY ORGANS. 437 

the pebbles, etc., are firmly wedged, the piece of tape will come out 
alone, and the entire procedure will have been a failure. 

All these methods of extraction require the utmost tranquillity 
and steadiness on the part of the patient, which cannot be expected, 
especially from a child. Hence, chloroform will have to be employed 
in most cases, and will be found to immensely facilitate the manipula- 
tions. Otitis and otorrhcea, which result from this accident, must be 
treated according to the principles already prescribed, but they also 
subside, even without any treatment, much more rapidly than the 
cachectic otorrhoea. 



CHAPTER VI. 

DISEASES OF THE GENITO-URINARY ORGANS. 

K.— KIDNEY. 

(1.) Malfoiimatio:n^ of the Kidneys. — The kidneys are never 
totally absent ; even in the most incomplete abortions they may be 
detected in some form. One kidney only is to be found in some 
cases, in which condition MoMtansJcy makes a distinction between 
the smgle and the shnple. In the former, a single kidney is found 
at the normal place, to the right or left side of the vertebral column, 
differing in shape but little from the ordinary kidney, while on the 
opposite side there is no trace of a gland. The simple kidney, on 
the other hand, is an abnormal fusion of two kidneys, the most com- 
mon form of which is the horse-shoe kidney {ren unguiformis). In 
this case two separated glands of normal shape are united at the 
lower end by means of a flat bridge of renal substance. The more 
limited this connection becomes, the more distinct the form of the 
siraple kidney appears. Finally, also, the two hila fuse together, 
forming a single hilum on the anterior surface. The simple kidney is 
always situated lower in the abdomen than the normal gland, and, as 
a rule, lies in the vicinity of the promontory of the sacrum ; seldom, 
like the single kidney, external to the median line. 

Besides this condition, various other minor deviations in form also 
occur, and in this connection it may be observed that the kidney of 
the new-born child, in the normal state, has a slightly uneven surface, 
and is nearer spherical in form than in the adult, and tapers some- 
what toward the upper end. 

(2.) Ueic-Acid iNFAECTioiq- OP THE New-boex {Infarctus Be- 
nalis). — Uric-acid infarction is a recent discovery, the merit of which 



438 DISEASES OF CHILDEEX. 

is due mainly to Vemais, Migel, 8c1ilos8bergei\ Yirchow^ Hessling^ 
and Martin^ of Berlin. The infarction manifests itself in sharply- 
defined, golden-yellow streaks in the pyramids. These streaks rmi 
together concentrically in the papillae, and for that reason are also 
found thicker there. Under the microscope they are recognized as 
small cylindrical columns, which, on being strongly compressed, 
crumble do^yn, and a reddish powder appears, consisting of amor- 
phous lithates, epithelium from the straight urinary tubules, and 
small rhomboid crystals of uric acid. When these golden-yellow 
streaks are found in the papillae, some of them will also be seen pre- 
cipitated as a carmine-red powder in the pelvis of the kidney, and in 
the most dependent part of the bladder. 

Urinary infarction is met with in two-thirds of all the children 
who die before the tenth and after the second day of life. It is very 
rarely seen in still-born, and but seldom in children who have respired 
one day. On the other hand, however, it frequently exists longer 
than after the tenth day, and, exceptionally, is even found in children 
who have lived for more than four or even six weeks. 

That this is not a pathological, but a physiological condition, is 
manifest from its frequency, from the absence of all morbid signs dur- 
ing life, and from the fact that the condition is almost invariably 
found in children dying before a certain age from other diseases. 
This phenomenon, according to Virchoio, is very easily explained in 
the following manner : Immediately after birth, a more rapid oxida- 
tion of the tissues, in consequence of the processes of respiration, 
takes place, as a result of which, among other products, uric acid is 
formed. This substance, combined with the alkaline bases, is ex- 
creted by the kidneys, but as yet does not find the requisite quantity 
of water in the new-born child to produce its solution. The large quan- 
tities of the excreted urates then accumulate in the straight tubules, 
and appear yellow, for they are combined with the coloring matter 
of the urine. The urine, which subsequently is excreted in larger 
quantities, and is consequently more diluted, partly dissolves it, 
partly washes it onward into the bladder, and thence outwardly. 
A red powder, in fact, is now and then found in the diapers of most 
of the new-born children, which, on close examination, is seen to 
be uric-acid infarction. This explanation, it is true, is not adapt- 
able to the extremely rare occurrence of lithic-acid infarction in the 
stiU-born, and therefore it is evident that it is not completely 
exhaustive. Although uric-acid infarction is to be looked upon 
as an undoubted physiological phenomenon, nevertheless it also fur- 
nishes causes for pathological conditions ; for example, it may give 
rise to the frequent passage of gravel, and nuclei for the formation of 



DISEASES OF THE GENITO-URINARY ORGANS. 439 

calculi. In truth, the germ of calculi in children always consists of 
lithic acid. 

Lithic-acid infarction, regarded from a medico-legal point, is not de- 
void of importance, for it is as positive a proof of Hfe as the dilatation 
of the lungs by air, and has the additional advantage over this sign 
that it does not become changed so quickly with commencing putres- 
cence. Aside from this, it has only an anatomo-pathological interest. 

(3.) MoEBUS Beighth (Bright's Disease of the Kidney). — In 
children, Bright's disease occurs in the acute form almost exclusive- 
ly, and only as a sequela of scarlatina. The chronic form is very rare, 
as I infer fi^om the fact that I have met w^th it only once — that 
single instance presented in a tuberculous boy ten years of age. It 
differs in no respect from the disease as it occurs in adults, and w^e 
may therefore refer the student to the latest text-books, and particular- 
ly to Fi^erichs's monograph, a model of exhaustive scientific essaying. 

We confine ourselves to a more detailed consideration of the acute 
form. 

Pathological Anatomy. — The kidneys usually exhibit those mor- 
bid alterations which Frerichs ascribed to the end of the first or 
commencement of the second stage. They are perceptibly enlarged, 
generally in consequence of an increase in bulk of the cortical sub- 
stance, which is of dark-red color, brittle, and friable. The cut sur- 
faces are very moist, and, on scraping them with a knife, a tenacious, 
bloody serum is obtained. Small extravasations of blood, of the size 
of a pin's head, are also frequently found. The pyramids are much 
less altered, and reveal nothing more than a greater vascular turges- 
cence, which produces a general dark color. 

The enlargement of the kidney is due to an exudation of fibrin, 
which fills up the tubuli contorti, and may be microscopically demon- 
strated in the fluid scraped from the cut surfaces. Numerous Bright's 
casts can be seen under the microscope, which are sometimes clear 
hyahne, sometimes again still surrounded by epithelium-cells, and 
perceptibly contain blood-corpuscles. These casts, though in much 
less quantity, are also met with in the tubuli recti, and are never 
totally absent from the precipitate of albuminous urine. When these 
children succumb at the very commencement of the disease, the urine 
will be found to contain so many blood-corpuscles as to color it dark 
red. After some time, it is clear, yellow, or turbid ; the blood-cor- 
puscles and coloring matter of the blood have disappeared, but albu- 
men and casts may still be detected. At this stage of the case the 
cortical substance exhibits more the character of the second stadium, 
according to Frerichs's division. 



440 DISEASES OF CHILDREN. 

It loses its dark color, and at first becomes pale yelloAv at various 
points, and finally all over. The blood-corpuscles in the plugged-up 
capillaries disintegrate, and are then, together with the coloring mat- 
ter, absorbed, or washed onward ; the exudation within the urinary 
tubuli likewise undergoes a retrograde formation, and the casts de- 
generate into fat molecules, and, although they still loosely retain 
their normal form, lose it when pressed by the glass cover under the 
microscope, consequently it is not always practicable to use it in the 
microscopical examinations at this stage. 

The kidney remains increased in bulk, and very brittle, the capsule 
may be pulled off with ease, and the upper surface is then seen to be 
slightly granular. This slight unevenness arises from the metamorpho- 
sis of the fat, and the succeeding atrophy, which does not progress 
uniformly on all parts of the cortical substance. ^Yhile one part is 
already flabby, and begins to waste, the other is firm with exudation, 
and occupies its former large space. 

In acute cases there is only found a very small quantity of urine 
in the bladder; in children who survived for many weeks after the 
attack, it may have returned to its former normal amount. 

Dropsical effusions into the peritoneal sac, pleura, and pericardium, 
are also found in almost all cadavers, often combined with inflam- 
matory exudation, especially upon the pleura. Those morbid altera- 
tions of the rest of the organs, which we constantly observe in the 
chronic form in the adult, do not occur in children. 

Symptoms. — The first signs of disease of the kidney usually appear 
at a time when the desquamation is at its acme, at the end of the third 
week of the scarlatina. The child who, to all appearances, is already 
perfectly well, and has a good appetite, suddenly loses it. It is seized 
with nausea and vomiting, and fever and debility again come on. The 
face, at the same time, assumes a puffed appearance ; the integument 
of the lower eyelids becomes elevated into glistening sacs, and, in a 
few hours, the entire surface of the body is affected by anasarca. 
Simultaneously with these phenomena, a palpable diminution of the 
secretion of the urine is observed. In the most acute form, the child 
will pass no urine at all for more than twenty-four hours, and finally 
void a few drops of blood-colored, concentrated urine, the act being 
attended by severe pains. In many cases, however, the urine is not 
very much diminished, nor bloody, but of a pale-yeUow tint, or pel- 
lucid, so that, on merely inspecting it, no alteration whatever can 
be detected. There is often also very sharp pain in the lumbar 
region. 

The chemical and microscopical changes of the urine are the same 
as in Bright's disease in the adult. In the first few days the quantity 



DISEASES OF THE GEXITO-URIXARY ORGANS. 441 

of albumen, -vylien no great amount of blood is admixed, is less than 
it is subsequently, and varies between ten and thirty pro mille. An 
approximative estimation of the daily loss of albumen may be formed 
by boiling a certain quantity of urine in a graduated test-tube, and 
allowing the coagulated albumen to settle for twenty-four hours. If 
the total amount of the daily discharge of urine is known, then it is 
easy to calculate how many cubic centimetres of albumen are voided 
in the urine. In children, however, the collection of the urine passed 
in the entire twenty-four hours is attended by considerable difficulty, 
and often entirely impossible, for they always discharge the urine 
along with the stools. 

The casts are found with the greatest certainty, and in largest 
quantities, when urine that has been voided some hours previously is 
slowly decanted, and the residue poured into a tall champagne-glass. 
In this glass the urine is again allowed to stand quietly for several 
hours, when aU but a few drops are poured off, and these last remain- 
ing drops are examined by the microscope. If no casts are found in 
urine thus prepared, it may be safely concluded that none exist. In 
all cases of acute Bright's disease, however, they are seen closely 
pressed together, and lying over each other, and, by examining and 
comparing a large number of these structures, we obtain a true insight 
into ithe nature of the entire disease. The casts possess different 
qualities, according to the duration of the disease, as already described 
in the pathological anatomy. 

The quantity of urine is generally lessened, the salts are likewise 
diminished, but the coloring matter in most cases is augmented. In 
the course of the disease, however, the urine again resumes its former 
straw-yellow color. The turbidness and sediments which are fre- 
quently present are partly due to the large quantities of casts, partly 
to the nrmierous epithelium-cells, and urinary salts. 

Should albujninous urine continue to be discharged for several 
days, the anasarca will increase, and the signs of dropsical effusions 
into the cavities of the body will become superadded. The abdomen 
becomes more and more protuberant ; complete dulness, when per- 
cussed in the sitting posture, is obtained over its lower part, and, in 
the recumbent position, fluctuation is distinctly felt. This, however, may 
arise from oedema of the abdominal parietes. The symptoms of hydro- 
thorax are still more striking. The greater the serous effusion into 
the pleural cavities, the more rapidly and laboriously do the children 
breathe ; the flat percussion-sound gradually rises, and only the rhonchi 
which are propagated through the ribs, and feeble or no respiratory 
murmurs, can be heard. The hydropericardium, which almost simul- 
taneously appears, makes the pulse irregular, flickering, and small ; 



4,4:2 ' DISEASES OF CHILDREN. 

the dulness in the preecordial region increases in circumference, but 
cannot be accurately defined on account of the close contiguity of the 
hydrothorax. These children sit upright, like croup patients, in their 
little beds, and sleep, if they are able to sleep, with the head thrown 
forward. They grasp firmly at the sides of the bed, in order to fix the 
pectoral muscles, and secm^e as gTeat a dilatation of the thorax as 
possible, and, with pitiful, beseeching looks, gaze about them in every 
direction for help. 

In progressive increase of the hydrothorax, the patients may perish 
from sujBfocation ; and, indeed, also oedema of the glottis, or ursemic 
symptoms, as a result of the grave renal disease, may supervene. 
These manifest themselves by headache, loss of vision and hearing, 
and by stupor and delirium, and death may also be brought about by 
exhaustion, through j)ersistent vomiting or diarrhoea. 

Hardly ever does a transition into the chronic form of Bright's 
disease occur in scarlatina. The children either die soon under the 
above-described symptoms, or, after two or three weeks, the albumen 
in the urine begins to decrease, the urine is passed in larger quanti- 
ties, the oedema and effusions into the serous sacs disappear, and this 
is followed by complete recovery. Of this I was once able to con- 
vince myself by the autopsy of the body of a child whom half a 
year previously I had treated for acute Bright's disease, but subse- 
quently lost by a violent typhus fever. The cortical substance of 
the kidney in this case was neither too large nor too small, and micro- 
scopically could in no respect be distingniished from that of the healthy 
kidney. 

All cases of nephritis, which appear with and after scarlatina, do not 
terminate with dropsy, because death ensues too early. Such are the 
cases of scarlet fever which rapidly terminate fatally in vomiting, 
coma, and convulsions, and then' unhaj^py issue is often erroneously 
ascribed to the severity of the fever, to the premature retrogTession of 
the exanthema, to hydrocephalus acutus, and, still more conveniently, 
to the intense toxic effects of the contagion. A more accurate inves- 
tigation of the cortical substance of the kidney, in most of these rapidly- 
terminating cases, reveals a marked alteration, like that foimd in the 
first stage of Bright's disease. 

Conversely, however, cases of oedema of the integument, after 
scarlatina icithout nephritis, or albuminuria, are also met with. This 
shnple anasarca, according to Frericlis^ is occasioned by exjDosure 
to cold during the period of desquamation, and is due to paralysis 
of the vascular systems of the integument and subcutaneous cellular 
tissue. 

The most contradictory statements exist concerning the occurrence 



DISEASES OF THE GENITO-UEINARY ORGANS. 443 

and frequency of nephritis after scarlatina. While some authors main- 
tain that two-thirds and even three-fourths of all scarlet-fever children 
are affected with it, others, on the contrary, claim that it occurs only 
once in twenty or thirty cases. The former hold that it is only neces- 
sary, in all cases, to thoroughly and accurately examine the urine, while 
the latter repel this reproach with indignation, and accuse their op- 
ponents of the grossest exaggeration. But it is possible for both to 
be right, for this depends entirely upon the character of the epidemic, 
and not upon the intensity of the disease. In some epidemics almost 
all scarlet-fever patients become dropsical, in others barely a few. 

Of one hundred scarlet-fever patients, dropsy was observed by 
Saidenhain in eighty per ct. ; by James Miller^ in twenty-seven per 
ct. ; by Wood, of Edinburgh, in twelve and a half per ct. ; by Hoseh, 
in ten per ct. ; and by Frerichs, in four per ct. of the cases. 

For a number of years back, scarlet fever has been prevailing 
endemically in Munich, but is only feebly contagious, and I have 
treated at least between fifty and sixty cases, and but twice only, 
and that temporarily, observed albuminuria. 

Treatment. — In this disease the physician renders the most effec- 
tive service by vigilant prophylaxis. The locality in which the patient 
is confined should be carefully tested for the state of the temperature, 
draught, and dampness, and that room should be preferred which can 
be properly warmed and ventilated, in which no unpleasant draught 
occurs from the opening of doors, and the walls of which are dry. 
Inunctions of fat, on account of the well-known properties they pos- 
sess of rendering the skin less susceptible to changes of temperature, 
are to be employed, even if they do not afford the degree of protec- 
tion which Schneemann ascribes to them. 

This regime is to be continued till the desquamation is entirely 
over, and the child, by a few baths, has again been habituated to 
greater changes of temperature. 

\^Tien dropsy and albuminuria have once appeared, the best means 
should be adopted to relieve the stasis in the kidney, by stimulating 
other secretions, such as the skin and bowels. Calomel, castor-oil, 
and subsequently also senna, are, by preference, selected from the 
class of aperients. Jalap and colocynth, and the salines, are w^ith 
justice avoided, because the salts are in greater part absorbed, and 
then eliminated by the kidneys. In" children who are at all predis- 
posed to diarrhoea, the utmost possible care must be exercised, other- 
wise a fatal enteritis may be produced. An effort should be made to 
stimulate the secretion of the sldn — Avhich, in anasarca, is much di- 
minished — by small doses of tartar, stibiat., or, when the children are 
very restless, by small doses of opium or camphor. The main atten- 



444 DISEASES OF CHILDREN. 

tion is always to be directed to the secretion of the urine. If this is 
properly reestablished, almost all the children, with good care and 
nursing, will recover, but, if it remains suppressed, diuretics should be 
employed to stimulate it. The best diuretic, the only one that is 
unattended by any unpleasant consecutive effects, and which can be 
given for a long time without disturbing the digestion, is roob 
jmiiperi, as fresh as possible. Children take it most readily when it 
is sweetened and diluted with a little water. Its dose is two or three 
teaspoonfuls in the twenty-four hours. I have often already con- 
vinced myself of the palpable good effects of this remedy, and in 
children prefer it to digitalis, bitartrate or acetate of potassa. 

Threatening uraemia must be relieved by vegetable acids and alka- 
line baths. For profuse diarrhoea, plumbi acetas, daily two or three 
grains, combined with opium, has proved to be most effectual. In 
case the oedema and albuminuria should not have disappeared in three 
or four weeks, as it generally does, a tonic treatment with tannin, 
cinchona, and the preparations of iron, is then indicated. For the 
remaining anaemia, the administration of wholesome, easily-digestible 
food, and the enjoyment of fresh country air, will answer the purpose 
satisfactorily. 

(4.) Renal Calculi, Renal Tubeecles, Renal Cysts. — Al- 
though concretions in the uropoetic system of children are of frequent 
occurrence, and have their foundation in the physiological lithic-acid 
infarction already described, still stones of larger dimensions very 
rarely form, at least such as would give rise to more decided symp- 
toms. In these cases there are very generally present severe renal 
pains, a purulent sediment in the urine, and the passing of small con- 
cretions, attended by violent pains in the course of the ureters and 
urethra. The pus in the urine is due to secondary inflammation of 
the pehds of the kidney, and of the irritated mucous membrane of the 
ureters and of the bladder. 

The treatment consists essentially in allowing the children to 
drink as much water as possible, for thereby the existing concretions, 
on the one hand, are more readily washed along, and, on the other, 
diluted urine must tend to diminish the gravel rather than to promote 
its deposits. When large ulcerations have formed in the pelvis of 
the kidney, fever will supervene, which quickly assumes a hectic 
character, and is soon followed by death; or the affected kidney 
may totally disappear, leaving the opposite one to perform a double 
duty. 

Renal tubercle occurs in two forms. In one case the kidney is 
simultaneously attacked with the rest of the parenchymatous organs, 
by miliary tuberculosis, which scarcely produces any renal symptoms 



DISEASES OF THE GENITO-URINARY ORGANS. 44,5 

at all, and is only discovered in the cadaver. In the other, the tuber- 
culosis in boys is more of a local nature, and extends upward from a 
tuberculous testicle, first to the mucous membrane of the bladder, and 
then to that of the ureters, and finally also to the kidneys. In this 
case a considerable portion of the kidney may be encroached upon by a 
large yellow, cheesy tubercle, and become excessively hypertrophied, 
the upper surface thereby assuming an uneven, nodular appearance. 
Suppuration, and degeneration even, occurs in the yellow tubercle, by 
which finally the tuberculous renal cavities, and ultimately phthisis of 
the kidney, are produced. The treatment of renal tuberculosis is very 
hopeless, and must be confined entirely to the improving of the con- 
stitution by tonics and cod-liver oil. 

Cystic formations are very common in the kidneys, and are even 
met with as congenital conditions. Obstetric cases are recorded in 
which the abdomen had become so distended by foetal cystic forma- 
tions in both kidneys, that it presented an impediment in the delivery. 
Simple cysts, of the size of a hemp-seed up to that of a cherry, are 
very frequently found in the most varying autopsies. They are al- 
ways situated very superficially in the cortical substance, and most of 
them are filled with a clear, pellucid, thin serum. The chemical in- 
vestigation of this serum reveals the presence of a slight amount of 
albumen, and only exceptionally of those chemical substances which 
characterize the urine, such as urates and lithic acid. It is generally 
assumed* that they are caused by an occlusion of some urinary tubules 
by uric-acid infarction, subsequently also by calcareous concretions, 
extravasations, and exudative casts. The acephalo-cystic sac and the 
comjDOsite cystoides are extraordinarily rare in the kidneys of children, 
and their consideration may therefore very properly be omitted. 

B.—BLADDEB. 

(1.) Malfoematio:n-. — (a.) Total absence of the Madder i^ SiTi e^- 
tremely rare occurrence, and is always combined with malformations 
of other organs. The ureters terminate in the navel, the rectum, or 
vagina. The following condition is more frequently observed : 

(b.) Fissure of the Bladder^ Prolapsus, s. jEJxtroversio, s. Defectus, 
s. Ectopia, Jnversio Vesicm Uriiiarice. We understand by all these 
denominations a defect of the anterior wall of the bladder, and of the 
corresponding portion of the abdominal parietes, so that the posterior 
wall of the bladder lies freely exposed (PI. III., Fig. 10). 

Two forms, a total and a partial, are distinguished. In the fii'st 
the abdominal fissure extends from the navel to the pubis and genitals. 
In the second, a well-formed navel, normal genitals, and onl}" a small 



44(5 DISEASES OF CHILDREN. 

opening in the anterior abdominal parietes, exist. A highly-red 
chasm, of the size o£ a silver dollar or more, is found in the new-born 
child in the region of the bladder, which is bounded by a sharp cutane- 
ous ring. This red gap is only filled up after birth by the posterior 
wall of the bladder becoming invaginated in it through the action of 
the abdominal pressure during crying and defecation, appearing as a 
fleshy, soft, fluctuating tumor. This tumor is constantly moist and 
tenacious, and presents at each side, in its lower part, two small eleva- 
tions, which correspond to the place where the two ureters terminate, 
and are most distinctly recognized when the tumor is displaced a little 
upward. On closer examination the urine will be seen to ooze out in 
drops from these points, emitting its characteristic ammoniacal odor. 

After several years, the cutaneous ring, by increasing granulations, 
grows somewhat over the prolapsus, and thus diminishes the exposed 
surface of the mucous membrane of the bladder ; but a large portion 
of its posterior wall nevertheless remains uncovered. After a while 
the exposed portion loses the character of mucous membrane, and that 
portion above the ureters becomes dry, callous, and insensible ; below 
them the prolapsus frequently becomes excoriated, in consequence of 
the incessant flow of the ammoniacal urine over it, and acquires a fun- 
gous appearance. 

Complete fissure of the bladder always extends into the genitals. 
The penis is very short, close to the prolapsed bladder, and either 
totally or partially split. In the latter case, it has the appearance as 
if split from the urethra upward, so that the urethra is not a closed 
canal, but represents a trough, fissured on its upper surface. In exten- 
sive fissures, an oblong appendix, which is the split penis, hangs on 
both sides, and the line of division extends into the scrotum, on ac- 
count of which it may be difficult to discriminate the sex. This dis- 
crimination becomes still more diincult, when, as is usually the case, 
the testes still remain in the abdominal cavity. 

Analogous sjolittings occur in the female sex. The clitoris is di- 
vided, the labia majora and minora cloven, and the vagina is often 
totally absent. The perinasum is extremely short, and the anus is 
situated directly behind the genitals. It may even be advanced so 
far anteriorly that it terminates in the posterior wall of the bladder, 
and the feculent matter may likewise be evacuated by the prolapsed 
bladder. 

When the fissures are thus extensive, the rami of the pubis will be 
found developed in a rudimentary form only. They either simply ter- 
minate in the vicinity of the prolapsus, or are united to each other 
behind it by a narrow band. The peMs is very wide in its transverse 
diameter, but narrow antero-posteriorly. The sacrum and coccyx are 



DISEASES OF THE GENITO-UEINARY ORGANS. 447 

very much curved forward, to whicli are due the shortness of the peri- 
n£eum and the termination of the rectum far anteriorly. 

The effects of this deformity vary according to its extent. In all 
instances the patients afflicted with it generate a disgusting urinary 
odor, and suffer from constant excoriations around the openings of the 
ureters. In fissures of the penis, the highest degree of epispadia, or 
in imperfect development of the vagina, the individuals are naturally 
incapable of propagating the species. There is nothing in these de- 
formities incompatible with life, and cases are known where the per- 
sons attained to an age of even forty years. Indeed, Huxham de- 
scribes the very remarkable case of a woman who, afflicted with this 
prolapsus vesicae congenitus and cloacae, married in her twenty-third 
year, conceived, and gave birth to children. The husband of such a 
creatm-e deserves almost as much admiration as herself. 

Numerous hypotheses have been advanced in regard to the origin 
of ectopia of the bladder. The explanation given by J. Muller seems 
to be the most plausible. 

According to this author, the bladder is not formed through the 
reflection of a lamina, but merely by the gradual dilatation of the 
pouch, which, with the urachus, is pinched off from the sinus urogeni- 
talis. But the urachus does not originate through the reflection of 
a lamina, but is only the neck of the allantois, which primarily grew 
forward from the intestinal canal hke a small vesicle. From these two 
facts tT. 3fuller infers that we have not here to deal with an arrest of 
development, nor with a stopping of the bladder at a former stage of 
development, but he is rather of the opinion that the absence of the 
anterior wall of the bladder is due to a rupture of the sac which oc- 
curred at a time when the abdominal parietes were not yet complete- 
ly formed. This rupture must have its foundation in a transient or 
permanent impermeability of the iirethra, by which the urine that is 
accumulating in the bladder distends it to such an extent that it finally 
bursts. In this manner there originates an opening between the navel 
and the external genitals. The simplest form of this malformation is 
epispadia, escape of urine on the upper surface of the penis or above 
the pubes, but the ordinary effect is a large opening between the 
umbihcus and pubic bones. 

Treatment. — An operation, having for its object the closing of the 
defect by freshening the edges, and uniting them by the aid of needles 
or sutures, is to be entertained only when a permeable urethra exists ; 
but, even where this condition obtains, a very rare one, the hopes of 
the operation, so far as I know, are invariably disappointed by the ir- 
ritating effects of the urine, which constantly bathes the raw surfaces 



448 DISEASES or childken^. 

of the wound. Our efforts consequently are limited to the preventing 
and healing of excoriations, by securing the utmost possible cleanli- 
ness, and by pencilling the exposed surface with pm-e oil. When the 
child grows up, an attempt may be made by EarVs apparatus to lessen 
the disgusting odor. It consists of a hollow silver shield provided 
with a caoutchouc tube with a stop-cock, and is secured to the pro- 
lapsed bladder by a double truss. 

C. Cloacm. — Communications between the rectum and bladder 
have already been spoken of, in connection with malformations of the 
rectum. 

(2.) Catareh op the Bladder, Inflammation oe the Bladder 
(Cystitis). — This is a rare disease in childhood. It occurs as a result 
only of external injuries, or rough calculi, or from the misuse of can- 
tharidis, and at the close of grave diseases, such as typhus fever, chol- 
era, and small-pox. 

Pathological Anatomy. — These causes hardly ever produce more 
than cystitis mucosa, or catarrh of the mucous membrane. External 
injuries may, in very rare instances, occasion cystitis serosa, or inflam- 
mation of the serous coat of the bladder; or pericystitis, an inflam- 
mation of the connective tissue which loosely surrounds the bladder. 

The inflamed mucous membrane is deeply injected, and, when the 
disease has existed for some time, will have a grayish-brown tint, will 
be thickened, and large quantities of mucus found at the bottom of 
the bladder; even excoriations of the mucous membrane and diver- 
ticulee are occasionally observed. The most extensive morbid lesions 
are always seen when calculi having rough surfaces exist. 

Symptoms. — In some cases the vesical symptoms may develop 
themselves very rapidly ; for example, in children who are susceptible 
to cantharidis they may come on within twelve hours after the appli- 
cation of a blister. In calculi, on the contrary, they come on very in- 
sidiously, often improve, and then relapse. 

Pain and tenderness in the region of the bladder, rectum, and ure- 
thra, constant dysuria, voiding of a dark, turbid, and even bloody urine 
by drops, are the constant symptoms. In the severest grades of the 
disease — which, however, are never met with in children — there are 
also observed distention of the bladder, complete ischuria, fever, ty- 
phous and peritonitic sjmiptoms, sopor, green vomiting, collapse, cold 
sweats, etc. 

The urine always contains a large quantity of vesical epithelium, 
mucus, and pus, and, when first passed, it has a wheyish turbidity, but 
does not clear up completely, even when allowed to stand for a very 
long time, and precipitates a thick, tenacious sediment. It rapidly 
decomposes, generates ammonia, and produces a brownish stain even 



DISEASES OF THE GENITO-URINARY OEGANS. 449 

on silver instruments. In diphtheritic cystitis, only observed in badly- 
ventilated hospitals, and which is complicated with diphtheritis of 
other mucous membranes, large pieces of false membrane are also 
voided with the urine, attended by the most excruciating strangury. 

The course of cystitis varies very much according to the cause. 
That form produced by cantharidis passes off most quickly and surely. 
The urine becomes perfectly clear again in a few hours, is voided with- 
out any pains, and the symptoms disappear without leaving a vestige 
behind. Cystitis at the end of grave diseases lasts longer ; still even 
in this case, when the general recuperative process is active, it termi- 
nates after a few weeks in recovery. The prognosis of traumatic cys- 
titis depends upon the severity of the injury, but, in making it, it is 
well to bear in mind that, by virtue of the greater reproductive pow- 
ers in childhood, more extensive injuries may be recovered from, and 
gTeater deformities remedied in a given time, than in adults. 

The case is much worse in cystitis, caused and kept up by a cal- 
culus. Even here, it exceptionally happens that the catarrh, notwith- 
standing the existence of the stone, disappears, a result only probable 
when the stone is very smooth. Usuallj^, however, the inflammatory 
symptoms last as long as it remains in the bladder, disappearing to- 
tally after it has been removed. Children affected with calcuh and 
catarrh of the bladder do badly, both mentally and bodily ; and lithot- 
omy, if the diagnosis is sufficiently clearly estabhshed, cannot be too 
quickly practised, especially since this operation in children is incom- 
parably easier to perform, and less dangerous, than in adults. 

Treatment. — The removal of the cause is the most essential part 
of the treatment. Should a cantharidal vesicant be upon any part of 
the body, it should be removed instantly. It not very infrequently 
happens that mild vesicants remain for several days upon the skin 
without producing any topical inconvenience, and then suddenly ves- 
ical pains come on, and the ignorant relatives have not the least idea 
of the intimate connection between the worthless old plaster and the 
violent harassing symptoms. 

The patients should be ordered to drink as much as possible of 
almond-milk and emulsions of flax-seed, so as to dilute the urine ; and 
to partake of bland food, such as milk and broths, containing as little 
salt as possible. 

The quantity of urine in the bladder should be carefully controlled, 
and the hypogastric region often percussed. The catheter should 
be introduced as soon as any dulness is perceptible, and the urine 
drawn off. The instrument, however, should never be left in the ure- 
thra, for the access of air decidedly aggravates the inflammation. 

Thorough evacuation of the bowels should be obtained, but saline 
29 



450 DISEASES OF CHILDKEN. 

aperients must be avoided. Several calomel powders, of a few grains 
each, render tlie best service. For the strangury, moist warm cloths, 
laid upon the hypogastric region, have proved to be very effectual ; in 
sleeplessness, some preparation of opium and bitter-almond water may 
be prescribed. In chronic cystitis, several grains of tannin may be 
given daily, or injected into the bladder. Patients with calculus should 
be operated on under all circumstances. 

(3.) EsruEESis, Incontixentia Uein^, Mictio Involtjntaria. 
(The nocturnal micturition in bed.) — Constant dribbling, or an entirely 
involuntary passage of urine, often occurs in children, and continues 
till they are several years old ; but it is seen only in cases where 
marked cerebral affections are present, such as idiotism and chronic 
hydrocephalus. This condition is due to an actual paralysis of the 
bladder, of which the muscular coat, as well as neck, is involved, thus 
permitting the continual escape of the urine, though the bladder may 
contain but a moderate amount. This condition continues incessantly 
by day and by night, and should be distinguished from the nightly 
micturition in children othermse well-developed. 

The latter occurs much more frequently in boys than in girls, and 
in most instances lasts up to the twelfth year of life — in exceptional 
cases, even till the aj^pearance of puberty. It by no means depends 
upon great local or cerebral lesions, otherwise it would not regularly 
terminate in recovery, and would also persist during the day. In this 
instance an inferior degree of sensibility of the bladder to the irrita- 
tion of the urine must exist, as a result of which it does not indicate 
its condition during sleep, or the sleep must be so profound that the 
ordinary irritation of the urine upon the filled bladder does not rouse 
the child. The latter view seems to be sustained by the circumstance 
that many children affirm that they had distinct dreams of sitting upon 
the chamber and passing their water in the customary manner. They 
generally pass their urine in bed but once during the night, during 
the first few hours of sleep. I cannot see that slothfulness, bad 
habits, or negligence, satisfactorily explain the causes of enuresis 
nocturna. In most of the cases which I have observed, the children, 
through their own sense of honor, or on account of repeated punish- 
ments, had a lively interest in avoiding the accident, and yet were 
unable to do this without appropriate treatment pursued for months 
and even years. 

I am likewise unable to confirm the opinion of some authors, that 
chemical alterations of the urine may be the cause, for chemical inves- 
tigations of the urine, instituted in three cases of enuresis, taught. me 
that the urine does not in any manner vary from its normal quantita- 
tive nor qualitative composition. On the other hand, however, the 



DISEASES OF THE GENITO-URINARY ORGANS. 45 1 

statement, that most of the children suffering from this misfortune are 
not particularly blessed with perfect health, is correct, for they usually 
labor under scrofulous affections of the most varying kind, or under 
rachitis or helminthia. 

The effects of this malady are rather unpleasant, for the psychical 
development in particular suffers. The repeated punishments which 
these cliildren undergo blunt their sense of honor considerably ; they 
become cowardly and deceitful, and have no personal spirit. If great 
and expensive cleanliness is not practised, the bed, and even the whole 
room, acquires a urinous odor, which contaminates the atmosphere and 
begets conditions which are by no means favorable to the metamor- 
phosis of the tissues. Such children may be ultimately attacked by 
indolent ulcers on the nates and lower extremities, the results of the 
Luminous excoriations. 

Treatment. — A treatment directed to the removal of the cause may 
become necessary, when marked symptoms of intestinal worms, of 
scrofula or nervous hj^ersesthesia, become manifest, which must be met 
with anthelmintics, cod-liver oil, iron, cinchona, and aromatic baths. 
Lallemand praises the latter, in particular, very highly. He allows 
four or five handfuls of some aromatic species of herbs to stew in a 
covered vessel, and this decoction, together with a glassful of brandy, 
to be poured into the bath, which is covered by a cloth, so that the 
head of the child only is exposed. In this bath the child is to remain 
from one-quarter to haK an hour, and after several baths the quantity 
of the herbs and of the brandy may be doubled. These baths must 
be repeated daily or every other day for several weeks, whereupon a 
recovery ensues. 

The dietetic treatment consists in first taking the precaution that 
the child eats or drinks nothing for several hours^ -before retiring for 
the night, by which the secretion of urine is reduced to a minimum; 
and, although it may pass off involuntarily during the night, still the 
quantity will be very small. It is also advisable to make the patients 
sleep in the lateral posture, because it has been repeatedly observed 
that they invariably pass their water while lying upon the back, but 
remain clean when they sleep on the side. In order to prevent them 
from rolhng over on the back in sleep, it is suggested that a cloth or 
sheet be tied around the body with a large knot fixed exactly over the 
spinal column. The pain which it causes, when they attempt to roll 
over on the back, instantly rouses them. 

This advice sounds very simple and plausible, but always fails in 
its purpose, because children will not tolerate a band around the 
body, so tight that it would not become displaced through the night. 



452 DISEASES OF CHILDREN. 

They urinate in bed as mucli as ever, notwithstanding the knot, and, 
when they are raised np, it is found shoved over to one side. 

There is no necessity for the physician to advise any psychical or 
corporeal chastisement. Usually these remedies have already been 
fruitlessly employed, on the most extensive scale, before he was con- 
sulted. Still less are terrifying measures, such as the menace of ap- 
plying a red-hot iron, suggested by £oerhaave and Caspar^ to be 
permitted, or recommended, for a very injurious effect may thereby be 
produced upon the nervous system. 

Of the internal remedies, two are especially efficacious, namely, 
belladonna and nux vomica. 

Of the former, one-twelfth to one-sixth of the extract may be given 
every evening, the dose being increased till the pupils become dilated. 
By this treatment, the enuresis is arrested for several days, but it 
usually relapses ; yet it is not advisable to continue it for a long time 
with large doses. In many cases I have derived a much more durable 
effect from strychnine nitric. This preparation is jDreferable to the 
ext. nucis vomicge spirit., for the quantity of strychnine in the latter 
is by no means always uniform, and the gTadual increasing of the 
dose is, therefore, more apt to be attended by symptoms of poison- 
ing. It is best to give it in powder, simply triturated -with a little 
sugar. Children over three years of age are at first allowed one-thirty- 
second, then one-twenty-fourth, etc., up to one-eighth of a gTain; strong- 
coffee should be prepared and always .kept ready at hand in case symp- 
toms of poisoning come on, such as twitching of the muscles, etc., 
which are most certainly controlled by it. With this treatment, the 
object aimed at is usually attained in from eight to fourteen daj^s, and 
generally the cure is also permanent. 

The experiment which readily suggests itself, to tie the penis -with 
a piece of tape, and thus prevent the escape of the urine in a purely 
mechanical manner, is impracticable, for it causes oedema of the penis 
and erections. A case has occurred where a boy, from fear of the 
brutal chastisement which he was promised if he wet the bed, tied 
his penis so tight that he was unable to loosen the knot on the next 
morning, and the result was partial gangrene and a urethral fistula. 

(4.) IscHUEiA. Retention of Ueine. — Retention of urine in adults 
and children is a symptom of the most varying kinds of morbid con- 
ditions. Hence we have ischuria paralytica, spastica, inflammatoria, 
organica, and mechanica. Of all these kinds, but a single one, ischuria 
spastica, occurs in children. Nervous children, who suffer much from 
flatulence and colic, will sometimes pass no water for more than twelve 
hours, on account of which their attendants are thrown into the gTcatest 



DISEASES OF THE GENITO-URINARY ORGANS. 453 

anxiety. The patients become very restless, cry fearfully, draw up 
tbeir lower extremities against the abdomen, take the breast but 
little, and consume a small amount of fluid, but this enables them to 
pass a long time without urinating. It is not a very serious accident 
or disease, and I have never yet met with a case where actual me- 
chanical impediments had to be overcome. The only point which may 
be interesting is, that, in infants a few weeks old, the passage of hthic- 
acid infarction, in the shape of small, red, sharply-angular grains, may 
occur. 

The treatment is extremely simple, for the introduction of a 
shghtly-curved, well-oiled probe will always produce a discharge of 
m-ine immediately. To prevent recurrence of the vesical spasms, 
the apphcation of a bag of chamomile-flowers upon the hypogastric 
region is very useful. It is, in fact, much more so in children than in 
adults. 

(5.) Vesical Calculi, Calculus Vesicae. Lithiasis i^f^iaaiq^, 
— Calculary affections are comparatively frequent in boys. Nearly 
forty jDcr cent, of all the individuals operated on for Hthotomy are 
children under ten years of age, as is seen from the statistical state- 
ments of Proiit, who reported 1,256 cases of lithotomy operated on in 
the large hospitals of Bristol, Leeds, and Norwich. The reason for 
this singular circumstance is found (1), in the physiological uric-acid 
infarction, a few granules of which may readily remain lying in the 
bladder, and thus form the nucleus of the stone; and (2), in the quan- 
tity of the phosphates which occurs in the urine of rachitic children. 
In rachitis the urine becomes so rich in phosphoric acid and carbonate 
of Hme, that a decided stratum of white powder remains after the 
evaporation of the urine which these children leave on the floor, a fact 
to which my attention was once called by an observing nurse. 

All kinds of vesical calculi occur in children — the urate, oxalate, 
and phosphate. The lithic-acid calculi, consisting of this acid and 
its salts, are moderately hard, smooth, and most of them are yellow- 
ish brown in color, because the coloring matter of the urine is almost 
always precipitated simultaneously with the lithic-acid sediment, and, 
as a rule, forms the nucleus of the stone, although the external 
layers have a different chemical composition. Most of the calculi 
composed of phosphate of lime and triple phosphates are soft, light- 
colored, of light gravity, and rough on the outer surface. Oxalic- 
acid calculi, which in children form but very rarely, are the hardest 
of all, brown in color, and of a rough, nodular surface, on account 
of which they have also been called mulberry calculi. Calculi com- 
posed of cystin and those of carbonate of lime are extremely rare. 
The first-named calculi may also combine with each other, when the 



454 DISEASES OF CHILDEEN. 

nucleus will usually be found to consist of litMc acid and the outer 
strata of phosphates. 

There is generally but one stone in the bladder ; when several 
occur they grind themselves smooth against each other. Smooth calculi 
are very movable, while the rough and thorny calculi remain lying 
at some place at the base of the bladder, and become united with 
the mucous membrane. The effects of a stone vary according to the 
circumstances. There are patients with calculi w^ho have not the 
least traces of catarrh of the bladder, and experience scarcely any 
difficulties; in others, again, the voiding of the turbid, flocculent 
urine is attended by the most excruciating pains, radiating from the 
neck of the catarrhal bladder over the rectum, penis, and thighs. 

Symptoms. — The utmost care and skill are sometimes requisite to 
diagnosticate a stone with certainty. A correct diagnosis is of the 
utmost importance, because it determines the question for or against 
a dangerous operation. The most rehable signs, according to JPitha, 
are: 

(1.) The objective — the sensation of a heavy movable body in the 
bladder, which alters its position according to the attitude of the body 
— a symptom rarely observed in children. 

(2.) Pains in the neck of the bladder on standing, walking, sitting, 
and defecating, but which disappear by lying quietly for some time. 
Active exercise, such as running, riding in a wagon or on horseback, 
renders this pain intense beyond endurance, and the existing catarrh 
of the bladder then undergoes a marked aggravation, and finally bloody 
urine may be voided. 

(3.) These pains are often referred to the apex of the glans penis, 
and along the course of the urethra, causing the child to hold the 
penis constantly in the hand, and thus lead to masturbation. This 
habit produces a remarkable enlargement of the penis and elongated 
prepuce. 

(4.) Pain and difficulty in micturition. The pains become most 
intense toward the termination of the act, and last for a long time 
afterward. Occasionally the stream of urine is suddenly arrested and 
does not start again until the child has lain down or assumed a differ- 
ent position. The child accurately describes the sensation of a foreign 
body having suddenly interposed itself, and is able to displace it by 
changing its attitude. 

(5.) The most important sign is always derived from the examina- 
tion with the sound. An audible clang produced by the steel sound 
in the bladder cannot be due to any thing else than a vesical calculus. 
Moreover, by lightly touching the stone, and by the more or less clear 
tone thus produced, even an approximative idea of its hardness, smooth- 



DISEASES OF THE GENITO-URINARY ORGANS. 4.55 

uess, and mobility, may be obtained. The smaller the calculus the 
more difficult, of course, it is to find it. It is sometimes necessary to 
examine the patients in different positions, standing, lying on one side 
or on the other, or on the back, taking care that the bladder be filled 
or partly filled with urine. In some instances it may be felt by in- 
troducing the finger into the rectum. The exploration with the sound 
in children is seldom successful, and incomplete or impracticable with- 
out the aid of chloroform. 

The course of the disease is almost always the same. It happens 
only rarely that stones larger than peas pass off by the urethra, and 
still more seldom that they are evacuated through the vagina, rectum, 
or perinjeum, as a result of ulceration. 

If no artificial aid is rendered them, the patients will retain their 
calculi to the end of life, which, although attended by constant torture, 
may be protracted for many years. Ultimately they become atrophic, 
have hectic fever, loss of appetite, exhaustion, and sleeplessness, and 
perish miserably, or ursemic symptoms and nephritis become super- 
added, and these are speedily followed by death. 

Treatment. — There is only one indication, and that is, the removal 
of the cause of the disease, the foreign body from the bladder. This 
has already been tried by the most varying internal remedies, the so- 
called lithotriptica, and by direct injections into the bladder. The 
effect, however, of these calculary solvents is still extremely proble- 
matical. The waters of various springs are recommended, especially 
Yichy, Kreuznach, Eger, and Franzenbad. Of the internal remedies 
may be mentioned the alkaline carbonates, phosphate of ammonia, 
herba uv£e ursi, electro-magnetism, and weak injections of fluids, which 
concentrated are certainly capable of dissolving the stone, but in this 
state cannot, of course, be introduced into the bladder. 

The mechanical removal of the stone through the urethra succeeds 
only in very few instances in the female. The male urethra, on ac- 
count of its narrowness and length, is unadapted to this method of 
practice. 

We have, therefore, no other resource but its removal by a surgi- 
cal operation, by hthotomy or lithotripsy. The description of these 
two methods of operation belongs to the study of surgery, and is found 
magnificently delineated in Fitha^s Diseases of the Male Sexual Or- 
gans, Virchow's Pathology and Therapeutics. 

In regard to the choice of the operation, whether lithotomy or 
lithotripsy should be preferred, it is only necessary to state here that 
lithotomy is even better adapted to children than to adults. Accord- 
ing to the declarations of all experienced surgeons, children furnish 
an extraordinarily favorable ratio of recovery. The calculi are seldom 



456 DISEASES OF CHILDREN. 

very large, tlie reaction is mostly slight, and recovery speedily follows 
in almost all cases, while lithotripsy has to battle especially with the 
narrowness of the youthful urethra, on account of which also chloro- 
form has to be administered at every sitting, and the consecutive 
pains at the passage of the fragments are very severe. 

C.—MALF GENITALS. 
I.— Penis. 

(1.) JVIalformations. — (a.) Congenital Phimosis (from ^i/^o«, I 
bind tight). By this is imderstood a congenital lengthening, and at 
the same time tightening of the prepuce to such a degree that it is 
impossible to retract it over the glans penis. In httle boys, a certain 
degree of this condition is to some extent physiological, and very rare- 
ly only can the foreskin be pulled back entirely so as completely to 
expose the glans ; still, as a rule, it can be retracted so far as to allow 
the mouth of the urethra and adjacent parts to be inspected. 

If it is impossible in any manner to retract the foreskin sufficiently 
to expose the meatus, then the condition is called congenital phimosis. 
Usually the effects of this condition are trifling, for the orifice in the 
foreskin is generally sufficiently open to allow the mine to flow off in 
a stream. This superfluity of the prepuce decreases mth age, the 
apex of the glans at length becomes visible, and with the appearance 
of manhood the entire condition is relieved. 

A marked swelhng of the prepuce sometimes originates, partly 
from uncleanliness, partly from external injury, and partly as a result 
of balanitis, which is liable to so close the opening that urine is actu- 
ally unable to pass through the tumid orifice. The foreskin becomes 
expanded like a bladder, and discolored ; the child is very restless, and 
with cries of pain presses out a few drops only of urine through the al- 
most-totally-closed opening. Gangrene of the prepuce has even been 
seen to result from this condition. 

The firm adhesions occasionally met mth between the inner 
lameUa of the prepuce and glans penis are not congenital, but the 
effects of former ulcerative processes in these parts. 

Treatment. — Mild grades of oedema of the superabundant foreskin 
may be relieved by cleanhness and the application of a little oil. 
In more marked cases, with very smaU opening, the unnecessary tip 
of the integument may be removed in a very simple manner with the 
scissors. The external lamella of the prepuce then retracts more than 
the tensely-stretched internal one, and a short longitudinal incision 
should therefore be made, splitting it toward the base of the glans. 
The hps of the wound will soon arrange themselves pretty closely 



DISEASES OF THE GEXITO-UEINARY OEGAXS. 45 Y 

to eacli other, or tliey may be held in juxtaposition by a few serre 
fines. Tlie haemorrhage and consecutive oedema are but slight, and the 
cure is complete in a few days. 

(,3.) Congenital Paraphimosis. — It occurs with and without 
hypospadia, and is the result of a true arrest of development. The 
glans, from the earliest period of embryonic life, are not covered by 
foreskin, are imperforate, and the future meatus urinarius is only 
indicated by a white spot. Very gradually a fold of integument, the 
future prepuce, forms behind the corona glandis, rapidly grows for- 
ward, and soon covers the whole glans. The urethra in the mean time 
has become developed. An arrest of this growth, and the coalescence 
of this rudimentary prepuce with the glans, produce the condition 
known as paraphimosis congenita, or, strictly speaking, a defectus 
pr^putii congenitus. It is frequently combined with hypospadia, and 
the frsenulimi, in particular, is often so shortened that, during erection, 
the meatus is pulled downward. Von Ammon has made the remark- 
able observation that congenital defect of the foreskin not unfre- 
quently occurs in Hebrew boys. It would therefore seem that an 
artificially-produced defect of form may be inheritable. An analogue 
of this fact is found in the well-known one that tailless pups are 
much more frequently born in the races of dogs whose tails it is cus- 
tomary to cut off, than in other races which are not mutilated by this 
cruel custom. 

No therapeutic measures are necessary in this defect of the penis ; 
but, when the frasnulum is too short, and during erections drags upon 
the glans so as to be a source of pain, it may become necessary to 
divide it. 

(7.) Congenital Closure of the Meatus {Atresia Urethrm). — Either 
the orifice of the urethra only is agglutinated, or closed up by a mem- 
brane, or a larger portion of the urethra is impervious. In the first, 
the urethra, on micturition, is seen to expand up to the point of 
closure, and the defect may easily be remedied by a slight longi- 
tudinal puncture with the exploring trocar ; and in the second case, a 
very rare condition, and almost always complicated with hypo, or 
epispadia, the operation is very difficult, and ultimately the bladder 
will have to be punctured if it is not possible to discover the urethra. 

(^.) Anomalous Openings of the Urethra^ Hypospadia and Epis- 
padia. — In hypospadia the urethra is not closed on its under surface 
to the tip of the penis, but presents an open trough, so that the mouth 
of the urethra is not found at the point, but on the under surface of 
the penis. In the milder grades of hypospadia, where the opening is 
in the course of the penis, the individuals suffer no other inconven- 
ience than that the stream of urine does not flow directly forward but 



4-58 DISEASES OF CHILDREN. 

downward. Boys learn to correct this by holding the penis upward. 
In the cases of extreme degree of this defect, not only the whole 
urethra, but also the scrotum and even the perineeum, is fissured, and 
the bladder terminates directly into this chasm. This condition is liable 
to be mistaken for hermaphrodism, especially when the testes have 
remained in the abdominal cavity, as is generally the case. The sex 
in these cases can only be decided with certainty in later years, when 
the sexual characteristics of the individual develop, such as masculine 
voice, masculine form of body, and growth of beard. 

Hypospadia, according to its genetic character, is a true arrest of 
development ; for, in this condition, the urethra does not exist in the 
penis, but is represented in a rudimentary condition as a furrow ter- 
minating at various distances from the widely-separated testicles. 

The attempts to establish a normal urethra, and to close the anom- 
alous orifice by a surgical operation, are rarely successful, on account 
of the urine with its corrosive qualities flowing over the fresh wound. 

By epispadia is understood a S23litting of the urethra on its upper 
surface, so that its proper orifice is on the dorsum of the penis. The 
fissure is either limited to the glans, or extends throughout the en- 
tire length of the penis, and ectopia of the bladder may be looked 
upon as the highest degree of this malformation, a detailed descrip- 
tion of which has already been given on page 445. It is a much 
rarer condition than hypospadia. When the opening of the urethra 
is situated close to the glans, the child has normal control of the 
bladder, and learns to hold the penis, during the act of micturition, in 
such a position as not to wet its clothing. But when the aperture is 
near the root of the penis, then incontinence usually exists, and all 
the lamentable effects are superadded. Those persons only, who have 
the aperture in the urethra situated so far back that, during the emis- 
sion of semen, none enters the vagina, can be regarded as devoid of 
procreative abilities. 

(2.) Balanitis, Inflammation of the Peepuce (from (idiavog, 
glans). — In large boys the smegma prgeputii occasionally accumulates 
in large quantities, becomes hard, and undergoes chemical decompo- 
sition, and then causes inflammation of the glans and prepuce. This 
may also be produced by external injuries and constant playing with 
the foreskin. It may also occur in those who masturbate, and in 
patients suffering from worms. 

The foreskin is then seen to be swollen, its orifice agglutinated, 
and the most intense pains are induced when an attempt is made to 
retract it. The glans penis appears reddened, covered with pus, and, 
when it is completely exposed, large masses of a cheesy and fetid 
matter fall out from the fold of the prepuce. The cause of this inflam- 



DISEASES OF THE GENITO-URINARY ORGANS. 459 

matory disease is usually removed with these lumps, and in a few 
days it disappears. The cure is accelerated by lotions and com- 
presses dipped in lead-water. 

If the prepuce, on account of too severe oedematous swelling, can- 
not be retracted, the chief cause of this swelling of the smegma cannot, 
of course, be removed. The result will be an indefinite prolongation 
of the inflammation, the formation of abscesses, and even perforation 
of the foreskin. I once treated a boy for a very severe balanitis, whose 
prepuce could not be retracted by any means. Injections of oil and 
warm fomentations, which in other cases caused the oedema to disap- 
pear, proved ineffectual in this case. On the third day a bluish-black 
spot appeared in the vicinity of the frsenum, indicating circumscribed 
gangrene. At this time a bright spot became visible through this 
gangrenous membrane, which, on closer examination, was cut down 
upon and found to be a knot of a thread, which, upon being pulled 
out, proved to be quite long. The inflammation and gangrenous dis- 
ease were arrested by its removal, and the balanitis disappeared. 
This boy, after retracting the prepuce, had tied a thread around the 
glans, which soon swelled up, and then he was unable to untie it. 
The fear of punishment prevented him from confessing his unfortunate 
act, and he had therefore to wait until the thread made its way out in 
the manner described. But, as the gangrene did not involve a portion 
larger than the size of a pea, the effects were of little moment. 

The treatment of simple balanitis is limited to the removal of the 
smegma, subsequent cleanliness, and astringent lotions. There is no 
danger of union occurring between the prepuce and glans penis. 

(3.) Acquired Paraphimosis. — On account of the long, narrow 
prepuce, a paraphimosis originates in children much more frequently 
than in adults. Boys find a pleasure in puUing and retracting it so 
as to expose the whole glans. The narrow aperture of the foreskin, 
gradually and painlessly dilated by the globular glans, now contracts 
behind the corona glandis, and it requires more adroitness to return 
the prepuce in front of the glans than was necessary to pull it back. 
The alarmed child usually seeks to hide its disaster, the constriction 
in the mean time causes a marked oedema and deformity of the penis, 
and the parents, whose attention is finally attracted to it, are ex- 
tremely frightened by this strange form of the organ. If left to itself, 
the oedema of the glans will increase for several days, and the penis 
will become bluish and deformed. Spontaneous, gradual diminution 
in size will, however, take place in time, for the preputial orifice be- 
comes dilated, and the glans ultimately slips spontaneously behind the 
foreskin. I have never yet seen gangrene of the glans result from 
simple constriction of the preputial border. Once, however, from 



460 DISEASES OF CHILDREX. 

constriction by a thread, as has been related. The sKght amount of 
danger that attends the first form is, in fact, due to the distensibility 
of the foreskin itself. 

Treatment. — A more gratifying treatment than that of paraphi- 
mosis can hardly be found. Tlie extremely-alarmed mother brings 
what she considers a maimed child to the physician, and, after a few 
minutes, leaves him beaming with joy, for the glans penis, by the 
successful reduction of the prepuce, has been restored to its normal 
form. 

The entire operation of the reduction simply consists in this : the 
oedematous prepuce behind the glans is grasped between the two in- 
dex and middle fingers, while at the same time the glans is pressed 
backward by both thumbs ; a traction of the prejouce forward and a 
movement of the glans backward are thus produced, and the result of 
this manipulation is a gliding of the foreskin over the corona glandis, 
and the latter, in a short time thereafter, regains its normal shape and 
color. In neglected cases, the glans may first be reduced in size by 
allowing a stream of cold water to flow over the organ, and the un- 
avoidable pains attending the reduction are also thereby rendered less 
severe. 

I have met with many cases of paraphimosis, but so far have been 
able to reduce every one of them, and therefore beheve that those 
children's physicians, who advise the use of compresses of lead-water 
and various astringents until a reduction takes place, are not ac- 
quainted with the above procedure. 

No after-treatment is necessary, for the part, once reduced to its 
proper position, soon regains its normal Ibrm. There is also no dan- 
ger of any relapses, for the child who has thus been so terribly fright- 
ened has never any more desire to see his glans penis exposed. 

(4.) Onanism {Ifasturhatw). — This practice, though met with in 
girls, is far more common among boys, and its effects are less signifi- 
cant in the former than in the latter. The term, in boys, is applied to 
a habit of rubbing or kneading the penis with the naked hand. By 
this means it is brought into a state of erection, and finally an ejacula- 
tion of semen takes place if the boy be of sufficient age. Girls titillate 
themselves, either with the finger or some similarly-shaped object, in 
the vagina; but, as pain, redness, and increased secretion of the 
vaginal mucus, are very apt to result, the habit is often thereby 
promptly arrested in the girl. 

In boys the case is altogether different. They derive such intense 
delight from this practice that, notwithstanding the severest punish- 
ment, and their own best intentions, they are unable to desist from 
these unfortunate manipulations. They thereby become visibly ema- 



DISEASES OF THE GENITO-URINARY ORGANS. 461 

ciated and anj^mic, and remain backward in tlieir bodily and particu- 
larl}^ so in their mental development ; the integument of the lower 
eyehds turns to a brownish or bluish color ; they have an apathetic 
expression of the countenance and flaccid muscles. They become 
indifferent to amusements which they once enjoyed, and withdraw 
from all society, preferring to be alone, in order to indulge their pas- 
sion. The gait becomes unsteady and cumbersome, and the knees 
fall inward. The emaciation is most strikingly seen on the lower ex- 
tremities and lumbar region, while the penis increases disproportion- 
ately in length and thickness. The prepuce becomes shortened, and 
is as readily pushed backward as in the adult ; the slightest irritation 
of the penis sufiices to induce an erection. The effects of this practice 
upon health are more or less serious, depending upon circumstances. 
Tabes dorsalis and paralysis of the lower extremities are occasional 
though rare effects of this practice. 

Children who are the victims of this practice, either from symp- 
toms or instruction, are induced to exert themselves to their utmost 
to abandon the vice. The success of their effort very much depends 
upon the age at which they have contracted the habit. The later 
they have acquired it, and consequently the nearer they are to man- 
hood, the less severe the effects observed from it. Boys over ten 
years of age, by continual masturbation, finally bring about an ejacu- 
lation of a slimy and probably prostatic fluid ; but, whether this con- 
tains spermatic filaments, has not yet been ascertained, so far as I 
know\ The youngest child, so far as I have information, in whom 
masturbation has been observed, was a girl eleven months old. Ac- 
cording to Krafft''8 description, she alternately pushed both her little 
hands into the vulva with increasing violence and rapidity ; she drew 
up her lower extremities against the body, grinned, and uttered a 
loud cry. This report is unique, and it may be questioned w^hether 
the child had not an eruption or a foreign body in the vagina, whicli 
gave rise to the acts, as those of mere scratching. 

The majority of boys who masturbate suffer from the above-men- 
tioned effects, but many retain a blooming appearance, and thrive 
both bodily and mentally. House physicians of institutions which 
have large numbers of boys assure me that the majority of confirmed 
masturbators suffer no bodily detriment from it; and many robust 
men, with great procreative powers, who consult me for other indispo- 
sitions, confess that they masturbated for years during their youth. 

Causes. — The most common cause is the imitative instinct of the 
boys. A masturbator shows his curious performance upon his own, 
or perhaps upon the penis of an inexperienced boy, and from that ' 
hour the latter becomes addicted to this vice. Onanism, therefore, 



462 DISEASES OF CHILDREN. 

occurs much more frequently in boys who have been brought up in an 
institution than in those that remain in their own families. 

Every thing that causes erections promotes onanism. Among 
these causes may be enumerated heavy feather-beds, too nutritious 
meat-diet, alcohohc drinks, obscene pictures and stories. It may also 
be directly induced by itching eruptions on the penis, accumulation 
of smegma praeputii, and by oxjoiris vermicularis, which may crawl 
out of the rectum, and into the vagina, or under the foreskin. 

Treatment. — According to the statements of an experienced physi- 
cian to an institute, nothing can be done with medicines for onanism. 
All that can be done is to render the practice of the evil as difficult as 
possible by exercising a strict surveillance. For this purpose guards 
should be kept constantly in the sleeping-rooms to watch and to 
punish upon detection. The mattresses should be hard; the cov- 
erings ought not to be feather-beds, but blankets of wool or cotton, 
through which the contours of the body are more easily perceived. 
The children should be punished very severely, yet the cause must be 
kept secret from the rest. It is of the greatest importance that as 
few boys as possible know of this -v^ce, and, for that reason, the speedy 
dismissal of the masturbator is the best remedy against its spreading. 
The utmost care should be taken to eradicate the causes mentioned 
above. It is not politic to examine often and minutely the penis of 
boys who are suspected, but not proven guilty, for the attention of the 
innocent might thus be attracted to it, and they thereby become ad- 
dicted to it. Cold affusions and baths are very valuable remedies for 
the effects of onanism, such as emaciation and imperfect development. 
Under no circumstances should iodine, or mineral waters containing 
iodine, be employed for the obesity which sometimes appears in these 
children, and on account of which they acquire an extremely comical 
appearance. Iodine given under these circumstances is liable to in- 
duce emaciation and tuberculosis. 

The threaterdngs which are resorted to by some teachers and 
guardians are, on the whole, very improper ; the health is infallibly 
imdermined by them, and death soon foUows. They certainly often 
induce the boys to stop their pernicious practices ; but they relaj^se into 
a state of deep melancholy, which follows them up to manhood. Proper 
bodily chastisement serves just as good a purpose, and this sad mental 
condition is totally avoided. 

II.— Testes. 

(1.) Cbtptoechidia (from /cpuTrrd^, concealed^ and opx^Q, testicle). — 
In the ninth month of foetal life, the testicles pass out of the abdo- 
men and descend into the scrotum, and a boy at full term comes into 



DISEASES OF THE GENITO-URINARY ORGANS. 463 

the world -s^dth both glands in the scrotum. Seven-months children 
are generally delivered with empty scrotums, the testes not having 
yet descended. One or the other testis — seldom both — is sometimes 
absent from the scrotum even in children at full term. They remain 
some time in the abdomen, or in the canal before descending. About 
ten per cent, of all boys present some of the forms of this irregular- 
ity. In the great majority of these cases the testicle descends 
without producing any symptoms during the first few weeks of life, 
so that older children are but very rarely met with who have but one 
testis in the scrotum, and still more rarely with none. These persons 
are called monorchides, testicondi, cryptorchides. The last is the 
most appropriate denomination, for they certainly possess not one but 
two testicles, which, however, cannot be found in their proper places. 
If an opportunity occurs to make an autopsy upon a cryptorchis, the 
retained testis will not be found in its original anatomical place, in 
the lumbar region, in front and below the kidney, but usually at the 
entrance of the canalis vaginalis, or within it, or in front of it in the 
lumbar region, where it may also be detected during life, as a hard 
elhptical tumor, painful when strongly pressed. 

Nature occasionally completes the descent at puberty — descensus 
testiculi serotinus — a process unattended by any symptoms, and totally 
unobserved. The testicle, however, never descends quite to the bot- 
tom of the scrotum, for the spermatic cord has been shortened and 
prevents it. In other cases a violent bearing-down pain is said to 
occur, and it is even affirmed that persons have died from it. The 
mechanical cause of death, so far as I am aware, has not been very 
clearly elucidated. It is, perhaps, caused by gangrene of the con- 
stricted testis. 

According to Von Ammon, the testicle may also make a false pas- 
sage for itself, and appear in the groin, where it may be mistaken for 
a crural hernia, or it goes to the perinasum. No other unhappy results 
of cryptorchia occur ; impotence, in particular, is not caused by it. 

This malformation cannot be remedied by any aid of art. There 
is no remedy that will extricate the testicle that has remained in the 
abdominal cavity, and nothing but injury will be done by any attempt 
at accelerating its descent from the canal by the aid of expulsive 
trusses. Compressive means are not advisable, even when a laiuckle 
of intestine escapes from the canal at the same time with the testicle. 
The best thing to do in this case is, to wait till the testis has en- 
tered the scrotum, then to reposit the hernia, and retain it by a good 
truss. 

(2.) Htdeocele. — A serous double sac, the tunica vaginahs pro- 
pria, envelops the testis and epididymis, and in the physiological state 



4,Q4: DISEASES OF CHILDREN. 

contains but a few drops of serum, sufiBcient to lubricate the serous 
surfaces. In hydrocele, an augmentation of this serum distends the 
sac ; its outward surface is nowhere in contact with the inner, and the 
scrotum has undergone a ^dsible enlargement. We 'designate this 
condition by the name of hydrocele. 

In young children, hydrocele occurs extremely often ; usually only 
one side is affected. In most instances it is indebted for its origin 
to an imperfect closure of the canalis vaginalis, after the testicle has 
descended to the scrotum. This permits the secretion of the whole 
peritonaeum to descend into the scrotal pouch of this membrane, 
which becomes distended and produces a hydrocele. It is not con- 
genital in the strictest sense of the term, for it originates a few 
weeks or months after birth. But the predisposition to it, the open 
vaginal canal, is congenital, and the same may therefore be said of the 
hydrocele itself. The following four kinds are distinguished : 

(1.) Hydrocele canalis vaginahs testiculi aperta (PI. III., Fig. 11). 
This form of hydrocele is rarely seen well defined. It appears as an 
oblong tumor, extending from the base of the canal downward to be- 
neath the testicle, which testicle cannot be felt at aU, or but indis- 
tinctly ; the spermatic cord, on account of serous infiltration, is dis- 
tended to the thickness of a common lead-pencil. The characteristic 
feature about this form is, that the tumor becomes markedly more 
tense and larger at the moment the abdominal viscera are crowded 
downward by the act of inspiration, and smaller and softer again with 
the expiration. The same happens when the scrotum is raised up, by 
which its contents flow^ back into the peritoneal cavity. Sometimes 
this can only be accomplished by the aid of pressure, especially when 
the canal is narrow. This condition is sometimes liable to be mis- 
taken for an external inguinal hernia. The form is the same, and the 
contents likewise reducible. Dropsy of the scrotum, however, is 
markedly translucent, flat on percussion, while a hernia always affords 
a hollow sound, and the testes cannot be isolated in hydrocele as in a 
hernia. Indeed, the manner in which the tumor disappears suffices for 
the experienced diagnostician to distinguish the two conditions with 
certainty. In hernia, the gut retreats suddenly with a gurghng noise, 
while in hydrocele the tumor decreases slowly and steadily, not by fits 
and starts. 

(2.) Hydrocele fundi canalis vaginalis testicula clausa (PI. IH., Fig. 
12). This is by far the most frequent form. Generally it is not con- 
genital, but makes its appearance a few weeks after birth. The tumor 
is round, transparent, and cannot be diminished by pressure. The 
testicle is situated above and behind, and can be felt but imperfectly. 
The spermatic cord is perfectly normal. This hydi'ocele is often bi- 



DISEASES OF THE GEXITO-URINARY ORGANS. 465 

lateral, and then, owing to tlie uniform enlargement of both scrotal 
sacs, is not so readily observed by the relatives as when one side only 
is affected. 

(3.) Hydrocele colli canalis vaginalis aperta (PI. III., Fig. 13). 
Here the spermatic cord is found filled with water, and dilated from 
its commencement in the abdominal cavity, down half-way, more or 
less, into the scrotal sac, while, in the depth of the scrotum, a per- 
fectly-normal testis is distinctly felt. The tunica vaginalis surrounds 
the testicle completely, and is dropsically distended in that portion 
above the testicle onlj^ Pressure does not reduce the size of the 
tumor; the serum may be forced back into the peritoneal cavity, but 
the spermatic cord, on account of the hypertrophy of the tunica 
vaginalis, never becomes as thin as the one on the sound side. Her- 
nijB may readily become superadded to this, and to the form described 
in sub. 1, as the vaginal canal remains open. It is sometimes not an 
easy matter to distinguish this condition from hernia. The disappear- 
ance of the tumor, whether slowly or suddenly with a gurgling sound, 
is the cardinal point in the diagnosis of hernia intestinalis. As this 
form is very rare, however, we are not often likely to meet with the 
difficulty attending its diagnosis. 

(4.) Hydrocele colli canalis vaginalis clausa (PI. III., Fig. 14). 
Here the spermatic cord, at its point of exit from the inguinal ring, is 
of a normal thickness, and continues in this manner for a short dis- 
tance, then suddenly becomes distended to an oblong cyst, which ter- 
minates as abruptly below ; the testis, as in the preceding form, is of 
a normal size and consistence. These conditions are best recognized 
by first ascertaining the locality of both testes, comparing them with 
each other, an^ then by pulling lightly the testis on the diseased 
side ; by this the examination of the spermatic cord is much facilitated. 
This form occurs tolerably often ; it is usually, however, monolateral. 
It may, indeed, be displaced, as a sound spermatic cord occasionally is, 
and cannot be felt. As a rule, however, pressure does not diminish 
the tumor of this condition, for the vaginal canal is closed. 

These comprise the various forms of hydrocele in children. The 
second and the fourth forms are the most common, while the first and 
the third are rarely observed. 

The contents of these hydroceles, if they have not yet been subjected 
to any active treatment, are thin, pellucid, light-yelloAV serum, having 
the chemical composition of the serum of the blood diluted with water. 
If it has often already been punctured, or a seton been drawn through 
it, or irritating ointments rubbed in upon it, the fluid that then escapes 
on puncturing it is of a milky turbidness, and exhibits a large number 
of cells. 

30 



4,QQ DISEASES OF CHILDREN. 

The spontaneous course of all the forms is, although tardy, almost 
invariably favorable. A hernia prolapsed through the unclosed inguinal 
canal is an unfavorable complication, as it is thereby prevented from 
closing, and the absorption of the hydrocele is retarded. In almost 
all the other cases spontaneous absorption of the effused fluid takes 
place in the course of time, although often not till after many months. 
A thickening of the tunica vaginalis propria only remains behind. 
Absorption occurs even in the rare cases of hydrocele which communi- 
cate with the peritoneal cavity; the inguinal ring generally becomes 
closed when the lower extremities are more freely exercised. 

Treatment. — Since almost all hydroceles, in children who have not 
yet passed beyond the first year of life, get well spontaneously, it is 
only a question of promoting this cure by Nature, with appropriate 
means ; those most generally regarded as such are dry warmth, aromat- 
ic fumigations, astringent fomentations of ammonia and vinegar, wine, 
diluted tincture of iodine, etc., and finally compressing the tumor by 
adhesive plaster or collodium. The congenital open hydroceles heal 
quickest, when their contents are forced back into the peritoneal cav- 
ity and retained there by a truss. The simplest and surest remedy, 
after all, is acupuncture. This may be performed with any plain 
sewing-needle. The scrotum is made tense over the tumor with two 
fingers, and then it is punctured several times in succession. A drop 
of the serous fluid follows each punctuer, but, while the external 
openings in the skin instantly close again, the perforations in the 
tunica albuginea remain open much longer, and the serum now escapes 
into the other textures, producing an oedema of the scrotum which, 
after a few days, is spontaneously absorbed ; the external and internal 
lamellae of the tunica vaginalis have in the mean time become so firmly 
consolidated that no future effusion can occur. Tliis little operation 
may subsequently be repeated without any harm, if the first trial be 
not entirely successful. 

Hydrocele in older children, and that of the spermatic cord, disap- 
pear also without any surgical interference, by the simple use of 
iodine locally. 

T).— FEMALE GENITALS. 

(1.) Malfoematioxs. — Malformations of the female sexual organs, 
in general, are rarer than those of the male, and with few exceptions 
are only discovered at the time of puberty, for the symptoms which 
they occasion first appear with pubescence. 

In order to thoroughly comprehend these malformations, it is ne- 
cessary to learn from embryology that the uterus, Fallopian tubes, 
and vagina, are developed in such a manner, from the canals of Miiller, 



DISEASES OF THE GENITO-URINARY ORGANS. 46T 

that the lower part of the latter is converted into the canalis genitalis, 
and that a transverse indentation then follows, by which it is divided 
into two portions, the uterus and the vagina. For this reason all these 
malformations may be arranged, according to Veit, in two classes : the 
first orio'inates through a defective development of one or both canals 
of Mliller ; the second through an abnormal union of the two canals in 
all other respects perfectly developed. 

First class: (a.) The canals of Mliller have been entirely arrested 
in their development, and therefore neither uterus nor vagina exists. 
The external genitals terminate in a short cul-de-sac. (b.) The vagina 
is present, of a normal length, but the uterus is absent, or it is only 
rudimentarily developed, (c.) Yagina and neck are of normal size, 
but the body of the uterus, owing to the defective coalescence of the 
commencing portions of the canals of Mliller, is divided — uterus bicornis 
— atrophic, and terminates in two atrophic oviducts. (d.) Only one 
of the canals of Mliller is deformed, or totally absent, by which the 
uterus unicornis originates. The corresponding ovary in this case is 
mostly normally formed ; on the whole, however, the ovaries in deform- 
ity of the uterus are generally also defective. 

None of these malformations give rise to any symptoms in chil- 
dren, and, as they produce no external alterations of form, remain also 
undiscovered. But, with the appearance of the menses, various dis- 
turbances come on, and a menstruatio vicaria becomes established in 
some other part of the body. 

Second class : (a.) The uterus is well developed, but its cornua are 
divided — uterus bicornis. (b.) The division runs through the whole 
organ, two vaginal portions project into the single or also double 
vagina, in which case even two hymens may exist, (c.) Externally 
no alteration of form whatever, or only a superficial groove, can be de- 
tected on the uterus, but its cavity is divided by a central septum into 
two perpendicular, adjacent compartments, uterus bilocularis. 

Even these malformations have no unpleasant influence upon the 
development of the child, and are almost always only accidentally 
seen in autopsies. A divided vagina and double hymen, however, 
will not escape detection. 

The conditions described as malformations of the external genitals 
usually are not really congenital, but form in the course of years from 
originally normal genitals. This is especially true of the enlarged 
clitoris, and the elongated labia majora, the so-called "Hottentot's 
apron." A partial closure of the external labia occurs besides, in 
small girls, who have suffered from severe deep diphtheritic ulcerations 
of those parts, and were not treated with a proper amount of cleanli- 
ness and care. 



468 DISEASES OF CHILDREN. 

(2.) Cataeeh of the Genital Mucous Membrane {Fluor 
Albus, Xeucorrhoea) . — Symptoms. — By fluor albus we understand such 
an augmented secretion, by the vagina and vulva, that the discharge 
makes its appearance in drops upon the labia majora, and may flow 
down upon the perinseum and thighs so as to soil the linen, and, drying, 
forms large crusts upon the labia. A secondary redness and swelling- 
are thereby produced, and in summer, if the parts are not kept clean, 
will result in ulceration of the external genitals and adjacent parts. 

At first the secretion is thick, bright yellow, homogeneous, but sub- 
sequently, toward the end of the disease, or in scrofulous girls, from the 
very beginning is viscid, muculent, filamentous, poor in cells, very 
much like the catarrhal mucus of the nose. If ulcerations have already 
formed, the blood derived from that source becomes mixed with the 
mucus and gives it a brownish color. It is not possible in httle girls to 
decide the place. of origin of this secretion, whether it comes from the 
uterus or vagina, for the hymen is always swollen and a dilatation of 
the vagina by the aid of small specula is very properly reluctantly 
resorted to. The rapid course of leucorrhoea in children shows plain- 
ly that the discharge comes from the mucous membrane of the vagina 
and not from that of the uterus, whereas blennorrhoeas of the uterus in 
the adult are well known to last for years, notwithstanding the most 
persevering treatment. 

If the crusts which agglutinate the external genitals are soaked 
ofi", and the vulva, external labia, and hymen are examined, they will 
be found oedematous, reddened, and painful to the touch. Urethritis, 
which manifests itself by the flow of pus from the urethra, and by 
severe pain on micturition, is sometimes, but not frequently, present. 
Older girls complain also of pain about the genitals, and walk, espe- 
cially when excoriations are present, with outspread legs, in order to 
avoid friction as much as possible. 

The course of leucorrhoea is always chronic, and I cannot recall a 
single instance that got well under six weeks ; still, there is always a 
better prospect of recovery than in adults. But, in children w^th ad- 
vanced tuberculosis and hectic fever, I have seen it persist till death, 
in an undiminished degree, and, at the autopsy, that warty granular 
condition of the vagina, which we so frequently observe in old leucor- 
rhoeas of the adult, was found. 

Causes. — It certainly cannot be denied that infection through 
gonorrhoeal virus occurs even in children a few years old. An unfortu- 
nate superstition exists among the public, that gonorrhoea of the male 
organ disappears when it is brought in contact with a hymen, and 
upon this behef many unchaste seductions are committed. Whoever 
has frequently examined and watched these unfortunate children will 



DISEASES OF THE GENITO-URINARY ORGANS. 469 

have noticed tlie singular, embarrassed, shy feeling they are affected 
with. If the simple question be put to them, where did the disease 
come from, ingenuousness vanishes, and they either protest their inno- 
cence with remarkable perfidious vivacity, or are thrown into a state 
of ^'isible embarrassment, and timidly answer, in an undertone, that 
they know nothing about it. If nothing strange can be perceived in 
the conduct of the child, it may be assumed with tolerable certainty 
that no infection has taken place, and a spontaneous or mechanical 
origin must be regarded as probable. If condylomata are present upon 
the labia majora and around the anus, there is no longer any doubt 
that a true infection has taken place. 

Leucorrhoea originates spontaneously, particularly in scrofulous and 
tuberculous children, living in damp houses. It is also produced 
mechanically by the introduction of foreign bodies, or from oxyuris 
gaining admission into the vagina, or lastly by onanism. The funnel- 
shaped condition and marked tumidity of the external genitals, so 
urgently insisted upon in medical jurisprudence as a symptom of rape 
having been committed, can only be of value after frequent repetitions 
of the act which make the condition well marked. No permanent 
alteration of form, not even any decided contusion or tumefaction, can 
ever originate from the simple contact of the glans penis with the 
h}Tiien. 

Treatment. — It is immaterial in the treatment whether the leucor- 
rhoea has originated spontaneously or from gonorrhoeal infection. In 
both cases cleanliness and daily baths render very important service. 
Those produced mechanically get well quickest — after a piece of 
wood, a bean, glass bead, or some similar substance, has been removed. 
These objects, however, are often concealed behind the hymen and are 
not easily found. The redness and swelling will disappear in a few 
days. 

When leucorrhoea is caused by oxyuris, the cure is about as easily 
effected by properly syringing the rectum daily with cold water, and 
the vagina, on account of its gTeater sensitiveness, with warm water. 
The prognosis is much worse when onanism is the cause of this disease. 
On account of the pain it causes, the girls do indeed stop masturbat- 
ing for a time, but they begin their pernicious practice iagain as soon 
as the irritation and pain have subsided, and thus constant relapses 
are produced, which can only be prevented by the strictest surveillance, 
which has to be continued unceasingly day and night. 

Leucorrhoea that has originated from contact with gonorrhoeal con- 
tagion lasts at least six weeks, and may persist for many months. 
The inflammatory affections, redness, pain, and swelling, are at first so 
severe, that the child is not able to walk, and the discharge rapidly 



470 DISEASES OF CHILDREX. 

excoriates the labia and thighs. The disease is also most obstinate, 
even when not gonorrhoeal, in very scrofulous or far advanced tubercu- 
lous children, in whom it lasts for years, and, when hectic fever comes 
on, will continue till death. 

To robust, healthy childi-en, in whom the disease was produced by 
infection, laxatives, jalap, senna, aloes, and neutral salts, may be 
given for a long time with advantage ; cachectic individuals, on the 
contrary, must be treated from the very commencement with tonics, 
iron, cinchona, and meat diet. 

The local treatment, on account of the smallness of space of the in- 
fantile genitals, is limited to zealous injections of cold or warm water, 
and the introduction of a piece of lint into the vulva at bedtime. 
Much benefit is derived from soaking this compress in a solution of 
alum ( 3 j to water 3 j) or of tannin (3j to water 3 j). Sulphate of 
iron and nitrate of silver are indeed also efficacious remedies in leu- 
corrhoea ; they, however, totally spoil the linen, and are therefore very 
reluctantly resorted to by economic mothers. 

In scrofulous children, sea-baths and the waters of springs contain- 
ing iodine (Heilbronn, Kreuznach), likewise cod-liver oil, render the 
best ser\-ice. Cutaneous diseases, eczema, impetigo, and prurigo, ex- 
isting upon the external genitals, must be removed as quickly as pos- 
sible b}^ cleanliness and desiccating ointments, for they are constantly 
bathed by the vaginal discharge, and the two evils act injuriously 
upon each other. 

(3.) DiPHTHEEITIS AND GaNGBENE OF THE FeMALE Ge:N^ITALS. 

Diphtheria rarely if ever occurs sporadically, but only in badly-venti- 
lated hospitals, foundling-houses, and orphan asylums. In this country 
it is in general rare, and is most frequently encountered during and 
after malignant ej^idemics of measles, when it also comes on in the 
overfilled, damp tenement-houses. Diphtheritis is no local, but a gen- 
eral disease, as has been already elucidated in the chapter on croup, 
and as is seen from the fever, rapid collapse, and generally fatal ter- 
mination. 

The disease begins like simple fluor albus, with redness and swell- 
ing of the vulva, but violent fever, hot skin, frequent pulse, and in- 
creasing thirst, soon supervene. If the labia majora are now sepa- 
rated, the mucous membrane will be seen covered with islands of 
white membraue. In shape they are sometimes circular, sometimes 
again very irregular, from the coalescence of several islands. At first 
it is not easy to remove them ; they, however, soon disintegrate into 
shreds, and leave behind them yellowish-gray bases, upon which, after 
the first shreds have fallen off, new membranous exudations quickly ajD- 
pear. The parts of the mucous membrane free from these exudations 



DISEASES OF THE GENITO-URINARY ORGAXS. 471 

are tumid, and of a dirty-red color. The odor of the sanious discharge 
is very offensive and persistent. The general state of the system 
indicates a grave disease, the fever assumes a typhous character, the 
ichor finally emits a gangrenous odor, the false membranes and the 
subjacent tissues also become gangrenous, and death ensues in a few 
days from the commencement of the disease. 

Gangrene of the vulva is caused either by diphtheria, or comes on 
like noma, in children who have just passed through a severe febrile 
disease, such as typhus fever, small-pox, scarlatina, or measles; Some- 
times it comes on so rapidly, and ivithout any subjective symptoms, 
that the attention of the relatives is first attracted by the gangrenous 
odor. This leads to a careful examination, when a few gangrenous 
vesicles, as a rule, are found upon the internal surfaces of the labia 
majora, which soon burst and give exit to a gangrenous ichor. In 
other instances, where the mortification has invaded the deeper struc- 
tures of the labia, the latter will become oedematous, assume a bluish 
color after the pains have existed for several days, and finally burst, 
when a large gangrenous surface will make its appearance. The 
mortification is mostly moist, spreads rapidly, and ultimately termi- 
nates in death. Besides the local destructions, catarrh of the mucous 
membrane of the air-passages, and frequently also pyaemic emboli in 
the lungs, spleen, etc., are found in the cadaver. 

Therapeutics. — The treatment of these serious diseases is very 
unsatisfactory. Internally, carbonate of potassa ( 3 j daily) is recom- 
mended as a specific in the diphtheritis ; usually, however, the fatal 
end cannot be averted even by this remedy. The stimulating treat- 
ment should be resorted to as early as possible, especially in gan- 
grene. Topically, the parts should be pencilled with concentrated 
mineral acids, or a strong solution of corrosive sublimate. The latter 
exercises a marked favorable effect upon the diphtheria, while in 
gangTene it has invariably proved inert in all those cases that I have 
observed. 

(4.) H-^MOEEHAGiA Vagin^ (Bleeding from the Vagina). — In a 
new-born girl, or in girls a few days old, a slight vaginal haemorrhage 
is observed in some rare cases. Usually, the bleeding is insignificant, 
and a few drops only ooze out from between the labia during the 
day. The breasts often swell up at the same time, and on moderate 
pressure will give exit to a few drops of milky fluid. 

Vaginal haemorrhage never becomes profuse, and as such is not 
dangerous ; but, in the two cases that I have had the opportunity to 
observe, profuse intestinal catarrh and atrophy ensued in a few days, 
a condition which, after all, may perhaps more justly be attributed to 
the want of the breast of the mother, than to the preceding hannorrhage. 



472 DISEASES OF CHILDREX. 

Billard and OlUvier cV Angers have often met -with these small 
hsemorrhages, but were unable to perceive anj bad effects from them. 

Therapeutics. — On account of the insignificancy of the bleeding, 
it does not seem advisable to resort to cold-water injections or the in- 
troduction of stj^tics for its jDrematm-e arrest. It is best to wait till 
it stops spontaneously; the warm water-baths, however, should be 
omitted so long as it continues. 

(5.) Inflaisimatiox of. the BpvEAsts (Mastitis JSTeonatorum). — 
We conclude the affections of the female genitals with mastitis neona- 
torum, although it does not exactly belong here, for it occurs as often 
in new-born bpys as in girls. To comprehend this peculiar process, 
observable only in the first few weeks of life, it is necessary to pre- 
mise that the breasts of most new-born children, when slightly pressed, 
will discharge a small quantity of thin milk, which, after eight to four- 
teen days in the male child, disappears forever, but in the female 
till the first pregnancy. 

According to Guillofs investigations, it is neutral or alkaline, but 
becomes acid if allowed to stand, and then separates into two parts. 
JMicroscopically, colostrum corpuscles are found in it in great abun- 
dance. It does not by any means taste sweet, but somewhat insipid, 
or even salty, of which I have frequently convinced myself. 

This temporary secretion of milk makes the breasts of the new- 
born child as disposed to inflammation as those of suckling women. 
Pressure or a bruise, which, during the delivery, may be unavoidable, 
suffices to induce inflammation and suppuration of the breasts. Med- 
dlesome midwives are often to blame for this affection, for they make 
the inexperienced mothers believe that the milk has to be assiduously 
squeezed out. Redness and swelhng of the gland result from this 
operation ; and at length, on touching the breasts, the child sets up a 
cry of jDain, the swelling increases, and fluctuation is finally felt at 
some j)lace ; and, when the abscess bursts, a large quantity of thick 
pus escapes. SujDpuration lasts for a few days, after which the abscess 
closes, the gland remains for some time indurated, but, after a few 
weeks, complete restitutio in integrum has taken place. In cachectic 
children who suffer at the same time from thrush and diarrhoea, the 
erysipelatous redness will extend over a large portion of the thorax, 
and, after spontaneous or artificial opening of the abscesses, large 
patches of cellular tissue will slough off, and fistulous ulcerations 
will remain for a long time. The only bad effect of suppurative 
mastitis in girls is, that the nijDple and even the whole gland may 
shrink up, when the mamma, thus altered, will be partially or totally 
unable to perform its function at the time when the duty of lactation 



DISEASES OF THE SKIN. 473 

Therapeutics. — A rational prophylaxis is the main indication. If 
the glands are swollen, but not yet reddened and painful, the transi- 
tion into suppuration, in most cases, may be prevented, if all pressure 
and irritation are carefully avoided, and the occlusion of the lacteal 
ducts obviated by inunctions of olive-oil. To accomplish the first 
indication, a fine piece of oiled linen is laid upon the breast, and over 
this some lamb's-wool. In this manner we may almost always succeed 
in reducing the oedema, and in bringing about a normal condition of 
the gland. But, if it nevertheless suppurates, the oiled linen is none 
the less useful, but the lamb's-wool should be changed for bags of dry, 
warm bran, because the ripening of the abscess is accelerated by them. 
In puncturing the abscess, the nipple should be avoided, for the cica- 
tricial contraction resulting from the wound will invariably pull it 
down and deform it, and this, in the after-life of the girl, may exercise 
a very unfavorable influence upon the nursing of her children. The 
incision should be in the direction of radial lines from the nipple as a 
centre. After the pus has escaped, plain, moist, warm compresses are 
applied, by which crusts are prevented from forming, and the lips of 
the wound from prematurely closing. In otherwise healthy children 
the wound will close in a few days ; in atrophic children, where col- 
lapse is vastly accelerated by the suppuration, the pus becomes floccu- 
lent, and thin, and the wound remains open until death. 



CHAPTER VII. 

DISEASES OF THE SKIX. 

All the diseases of the skin occur in children^ and most of them 
indeed much tnore freqiiently than in adults. As, how^ever, in the 
plan of this w^ork, a knowledge of special pathology, and also of the 
cutaneous afi'ections, is presumed to have been already acquired, we 
Hmit ourselves to the consideration of those morbid alterations of 
the skin which are almost exclusively observed in children ; or, if they 
also occur frequently in adults, require in children, on account of the 
greater delicacy of the skin, a diiferent treatment. Some of the dis- 
eases of the skin have already been described in former chapters, for 
example: seborrhoea capillitii, page 6; sclerema, page 67; cancer 
aquaticus, page 97 ; the eruptions during the first dentition, page 
107 ; in abdominal typhus, page 187 ; neevus vasculosus, page 242. 
Other markedly cachectic eruptions will be treated of with the ca- 



47i DISEASES OF CHILDREN. 

chexiae, syphilis, and scrofula, and tlius we have only remaining for 
this section the acute exanthemata, and a few chronic efiSorescences. 

(1.) ScAELET Feyer {Scarlatino). — Scarlet fever, as, in fact, all 
acute contagious exanthemata, is not to be regarded as a simple cuta- 
neous affection, but more as a general disease, of which the morbid 
alteration of the skin may certainly be looked upon as the most strik- 
ing symptom. It has always been the subject of attention from 
authors, to such an extent, indeed, that Canstatt collected a list of one 
hundred and ninety-one works upon this subject, which had been pub- 
lished before 1846. Since that date several dozens of works upon it 
have been added to the list. This large number of treatises is due to 
the ease with which it is observed, its frequent occurrence, and to the 
peculiar fact that almost every epidemic furnishes some slight modi- 
fication, which in former epidemics was but little and imperfectly 
observed. To simplify the study of this affection, we will first present 
a description of a regular scarlet fever, and all the variations and com- 
phcations will follow in a special section. 

K.— NORMAL SCARLET FEVER {SCARLATINA LEGITIMA). 

Symptoms. — Legitimate scarlet fever runs through three tolerably 
sharply-defined stages : (1), incubation and premonition ; (2), eruption 
and efflorescence of the exanthema; and (3), its disappearance, with 
final desquamation. 

1.) The Stadium of Ixcubatiox and Peemonitiox. — The in- 
cubation lasts from the day of infection till the appearance of the 
febrile chill ; thence the precursory stage is reckoned. This period 
is by no means alike in all children ; in most instances it lasts from six 
to eight days. Accounts of very great deviations from this are to be 
accepted with the utmost caution, for it is very seldom possible dur- 
ing an epidemic to determine the day of infection mth absolute cer- 
tainty. The opportunities for infection, by means of personal inter- 
course, especially with still-desquamating convalescents, or by trans- 
mission through a third person, are so variable and difficult to be con- 
trolled, that one may well doubt the statements which vary consider- 
ably from the general average, six to eight days. 

So long as it is not known that the children are infected, no s}Tiip- 
toms are usually observed during the period of incubation. But, when 
the parents have once ascertained that their child has been exposed 
to the contagion, from that hour they observe a host of symptoms, 
most of which are of a subjective nature, and furnish a more positive 
proof of parental anxiety than of medical acuteness. Some few cases, 
however, do in fact occur where the children feel unwell from the mo- 



DISEASES OF THE SKIN. 475 

ment of infection, are depressed, sleep restlessly, and have less appe- 
tite, till finally distinct febrile symptoms indicate the commencement 
of the precursory stage. 

The real premonitory stage embraces a period of from one to three 
days. The symptoms which appear during it are always so marked 
that the relatives notice them, yet are by no means on that account 
always the same. They do not, as a rule, possess much that is charac- 
teristic. Shght chilliness, hot and cold flashes, or a shivering chill, 
heightened temperature of the skin, very rapid pulse, severe thirst, 
anorexia, nausea, and, when the fever appears, sudden vomiting, 
are the ordinary phenomena. There is one symptom, especially 
during the prevalence of an epidemic, which makes the eruption of a 
scarlet fever more than probable, and that is a slight angina, occa- 
sioned by general redness and swelling of the whole posterior part of 
the mouth, palate, and fauces. The additional cardinal points for the 
diagnosis of a scarlet fever are remarkably hot breath, great frequency 
of the pulse, a burning-hot skin, and severe vespertine exacerbations, 
which may become aggravated into convulsions and delirium. 

After these symptoms have lasted one, or, at the longest, three 
days, the eruption begins to break out, and with it the second stage. 

2.) The Stage op EEUPTioiNr ai^b Floeescence. — The ex- 
anthema first appears upon the neck and face, then spreads rapidly 
over the whole body, and in twelve hours the eruption is at its 
height. It begins by the appearance of barely-visible, impalpa- 
ble, small red points upon the neck, quickly followed by a marked 
erythema. When the erythema does not uniformly cover the whole 
body, and occurs only in the form of large, red spots upon white, 
normal ground, then this kind is described as scarlatina variegata ; 
when the whole body is reddened, as scarlatina levigata. These two 
forms cannot be entirely separated, for often the one is observed on 
some parts of the body, while the other is seen upon other parts, and 
still more frequently the scarlatina variegata at the climax of the dis- 
ease becomes scarlatina levigata. 

Previously-healthy, well-nourished children become, in the true 
sense of the word, as red as " boiled lobster ; " the feebler the pa- 
tients, the less intense will be the erythema. The erythema is 
darkest in the vespertine exacerbations, and during bodily exertions 
or crying, and least intense when the children are uncovered and be- 
come cool. 

Normal, simple scarlatina lasts fully four days. During the first 
two days the redness of the sldn and general symptoms reach their 
climax ; in the next two the local as w^ell as the general subside. 

Simultaneously with the eruption of the exanthema, the anghious 



476 DISEASES OF CHILDREN. 

difficulties become considerably aggravated ; still, the angina of scarlet 
fever is never as severe and painful as a simple tonsillitis with marked 
tumefaction and incipient suppuration. The so-called scarlet-fever 
tongue is also most characteristic after the eruption. Its root and 
centre are covered white, its borders and apex colored dark red, 
the papillge filiformes are slightly swollen, and give it a granular ap- 
pearance, on account of which, and the similarity of color, the name of 
" raspberry tongue " has not unaptly been bestowed upon it. Occa- 
sionally the papillae are so intensely swollen that they also project 
boldly backward like red points, where the white fur has already 
formed, and thus make the tongue appear villous. 

During the first days the temperature of the skin is very high — 
higher, according to the sense of touch, on those places which are 
reddest. I once found it in the axilla, on the first day of the erup- 
tion, to have risen to 107° F. The pulse is likewise very high, and the 
thirst great. The profound general depression, which sometimes be- 
comes so serious, before the eruption of the exanthema, that the patient 
seems perfectly moribund, subsides after the eruption has appeared. 

Seini formerly claimed that scarlet-fever patients emitted a pecu- 
liar odor. The odor is described as very offensive, and has been com- 
pared to brine, old cheese, or even to that of a menagerie. Possess- 
ing extraordinarily acute olfactory nerves, I have with all carefulness 
sought this supposed specific odor in many patients, but have never 
yet been able to detect it. True, very many children smell unpleas- 
antly, but that is due to the circumstances that the parents will, un- 
der no consideration, consent to have the linen of the children and 
bedclothes changed; they even set them upon the chamber-pot in 
bed, and often will not touch them with a wet sponge for more than 
a week. From this there results a mixture of odors, to which fseces, 
urine, and perspiration, contribute the chief component parts. This 
so-called specific odor disappears in every instance so soon as the 
anus and genitals have been properly cleaned, the linen changed, and 
the children placed in a fresh bed. 

It is possible that, in Hehn's time, scarlatina was accompanied by 
such an odor ; in our time it is not the case. 

Toward the fourth day, all the local and general symptoms subside 
considerably. The angina disappears entirely, the exanthema fades, 
the fever is limited to the vespertine exacerbations which are growing 
feebler, the children sit up, begin to amuse themselves, and call 
for food. 

3.) The Stage op DESQUAMATioisr. — The erythema begins to 
fade on those places where it was first observed, on the neck and 
breast, and disappears last from the lumbar region and inner sur- 



DISEASES OF THE SKIN. 477 

faces of the tliiglis, where the last traces may be seen up to the 
sixth and seventh day from the commencement of the eruption. Pre- 
vious to the desquamation, a profuse perspiration and tolerably severe 
itching break out in most cases, after which the epidermis becomes 
cracked, and is cast off here and there in large scales or laminae. The 
new epidermis during the first few days is of a feeble rosy-red color 
and has a singular smoothness, but soon assumes the qualities of that 
just cast off. The exfoliation progresses upon the fingers and toes 
on a grand scale. It is here sometimes peeled off in continuous 
masses like glove-fingers. A similar process of desquamation also 
takes place on the mucous membranes. The patients hawk and ex- 
pectorate, without much difiiculty, a turbid phlegm, the tongue like- 
wise casts off its epithelium, the urine becomes opaque and contains 
enormous quantities of epithehum from the various sections of the 
uropoetic system. Lastly, several large, muculent stools, of a putrid, 
penetrating odor, are also evacuated. 

The desquamation usually begins directly after the exanthema has 
begun to fade, but may, however, be retarded for fourteen days. This 
happens especially when the recovery is interrupted by some inter- 
current process, for example, dentition or a catarrh of the bronchi, or 
of the alimentary canal, etc. The more intense the erythema, the 
more rapid and thick will be the desquamation. 

This is the picture of legitimate scarlet fever. Its variations are 
numerous, and can never be exhaustively described. They may be 
best regarded from the following points of view : (1.) Incompleteness 
or variations of form of the exanthema. (2.) Modifications in the 
participation of the mucous membrane. (3.) Intensity of the general 
affection ; and (4.) Anomalous localizations. 

■B.-VAEIATIONS OF SC ABLET FEVEB. 

1.) Incompleteness oe Modifications of Foem of the Ex- 
anthema. — Erythema of the skin and angina are the principal symp- 
toms necessary to constitute a perfect scarlet fever. When one of 
these two is absent, then we have the variation of an incomplete scar- 
latina, indicated according to the absence of the one or the other: (1), 
scarlatina sine angina; and (2), scarlatina sine exanthema. 

ad 1.) This form is observed tolerably often. The rash may break 
out perfectly, run a regular course, the desquamation may take place at 
the right time and properly, and yet the patients do not complain of 
any difficulty in deglutition and the tonsils are not swollen, scarcely 
reddened. The general symptoms are here never of especial severity, 
and the affection of the mucous membrane is always slight. 



478 DISEASES OF CHILDRE^^. 

ad 2.) However easy it may be to diagnosticate the first variety, 
it is by no means so easy to detect the second, for it is, indeed, pos- 
sible to mistake it for a simple angina, which children may also ac- 
quire during an epidemic of scarlet fever. The characteristic indices 
in scarlatina angina are : the difPused redness, the raspberry tongue, 
the rarity of suppuration of the tonsils, and the severity of the fever, 
all of which symptoms, however, may also occur without scarlatina, 
in simple angina of a nervous child. Angina of scarlet fever can only, 
then, be diagnosticated with certainty when the same individual has 
already, on a former occasion, been treated for a simple angina, and a 
marked difference in the form of the two fevers is perceived. 

Many authors assert that a child may also desquamate completely 
after scarlatina without exanthema. I have never yet observed this, 
and regard it more prudent, in real desquamation, to assume the exist- 
ance of an eruption, although of but a few hours' duration. 

Between these two forms there are, naturally, a number of inter- 
mediate ones. There are whole epidemics where the exanthema is 
comparatively severe, the angina slight, and conversely, epidemics 
where the angina produces very severe symptoms, while the exanthema 
is visible but for a short time, and only on some parts of the body. _ 

Regarding the form of exanthema, we have, first of all (1), scarla- 
tina variegata ; (2), scarlatina levigata. In the former, red patches, of 
the size of a silver dollar up to that of a hand, first appear, which may 
remain separated from each other by a streak of healthy integument. In 
the latter, the whole skin, from the face to the feet, becomes scarlet, 
in which case the desquamation is always extremely intense. At the 
acme of the exanthema the first form will, in fact, run into the second. 

"When the exudation of the cutis is considerable, a countless num- 
ber of minute tubercles will arise on the surface of the body, owing to 
which the integument feels rough, like a goose's skin. 

These nodules originate by enlargement of the papillas of the skin. 
This kind is called scarlatina papulosa. 

Lastly, when the exudation is still greater, the efiusion will gather 
into vesicles of the size of poppy-seeds, which are scattered in countless 
numbers over the whole body. They contain an alkaline turbid fluid, 
and an extensive desquamation ensues after these have ruptured. 

In some epidemics these vesicles stand so closely together that 
they coalesce, a condition that has been denominated scarlatina vesi- 
culosa, pustulosa, pemphigoida. Miliaries usually form only in very 
well-pronounced, severe cases. 

2.) MODLFICATIOXS rS" THE PaETICIPATIOX OF THE MuCOUS MeIT- 

BRAXE. — That scarlet fever is no cutaneous, but a general disease, is 



DISEASES OF THE SKIX. 479 

seen principally from the numerous affections of the mucous membrane 
that accompany it. 

On the usual places, in the cavity of the mouth, the morbid le- 
sions vary extremely in intensity. The palate and tonsils are either 
only sim23ly reddened, or reddened and severely swollen, or in malignant 
epidemics, under unfavorable external circumstances, may become 
covered with grayish-white membranes, forming angina diphtheritica. 
Most frequently the diphtheritic membranes occur upon the tonsils, 
and may be partially detached by gargling, when the mucous mem- 
brane beneath will be seen reddened, eroded, and after a few hours 
becomes covered again with new pseudo-membranes. The odor from 
the mouth is very offensive, deglutition is difficult, and a fetid mucus 
flows from the nose when the diphtheria extends upward into the 
choan^e. The adjacent submaxillary and cervical glands are then al- 
ways swollen and occasionally suppurate. The affection of the general 
system is always uncommonly grave, and collapse ensues rapidly when 
the diphtheritis becomes gangrenous ; along with which the odor 
from the mouth becomes intolerably putrid, great difficulty in degluti- 
tion and respiration, delirium or coma, come on, and these are soon 
followed by death. 

The angina likewise shows variations in regard to its extent. In 
benign epidemics, it is confined to the palate and tonsils, but, when 
the diphtheritic form appears, extends also to the Eustachian tubes, 
nasal passages, Highmorian cavities, pharynx and larynx, by which, 
according to the affected parts, deafness, corj^za, dysphagia, and 
dj'spnoea, supervene. Epidemics with diphtheritic, and, still more, 
gangrenous angina, always belong to the malignant. 

3.) Intensity of the Aefection of the General System. — 
Our predecessors assumed, (1), an erethitic, (2), a synochal, (3), a 
torpid, and (4), a septic scarlatina. Although this division into dif- 
ferent forms cannot always be strictly carried out, for often several of 
them are observed during the course of the same case, still it must be 
acknowledged that the character of the general reaction may be very 
different in different epidemics. To this variation, that seen individually 
is yet to be added. In general, it may be assumed that the stronger 
and healthier the child was before it was attacked by the scarlet fever, 
the more synochal or violent will be the reaction of its organism ; and 
the feebler and more cachectic, the more septic will be the symptoms. 

By erethitic scarlatina is understood a morbid condition like that 
we have presented above as a normal scarlet fever. The eruption 
and the local and general phenomena appear with no dangerous se- 
verit}^, and the termination is therefore always favorable. Still, such 
a result cannot always be predicted from the character of the pre- 



480 DISEASES OF CHILDEEN. 

cursory stage and eruption, for the cliaracter of the fever may change 
at any time. 

The synochal, inflammatory form is distinguished by the rapid 
appearance of the disease, violent fever, intensely-developed exanthe- 
ma, accompanied by miliaries, considerable angina, and cerebral phe- 
nomena, sleeplessness, delirium, headache, and intolerance of light. 

In some epidemics, the torpid or the nervous form is predominant. 
In this case the disease begins from the very first with great prostra- 
tion, vertigo, muttering delirium, syncope, and coma. The pulse is 
extremely rapid, but small, and readily compressed. The angina is 
disposed to take on the diphtheritic form. The exanthema breaks out 
only imperfectly on some parts of the body; the extremities are 
oftener cool than warm. The tongue becomes dry, as in typhus- 
fever patients ; in fact, even profuse diarrhoea comes on, and the pa- 
tients usually die very soon after, or between the second and fourth 
day. of the disease. No local causes sufficient to explain the death, 
as a rule, are found at the autopsy, so that we have to assume the 
influence of a supposed scarlet-fever poison upon the blood and ner- 
vous system. When children sm^vive this stage of the disease, they 
are still Hable to suffer from its sequelEe, and the convalescence in all 
cases goes on yery slowly. 

The septic form may be looked upon as the highest grade of the 
disease in which the eruption usually does not break out at all, and 
the diphtheria of the mouth soon becomes gangrenous, death ensuing 
in the shortest time it ever occurs in scarlatina, and preceded by the 
formation of petechi?e, profuse hgemorrhage from the nasal mucous 
membrane, from the bowels, and from the kidneys. 

4.) AjsroMAiOFS LocAxizATioxs. — The local lesions are not al- 
ways limited to the skin and mouth. In some epidemics other or- 
gans become involved. Thus it is reported of some epidemics, where 
many children, at the climax of the disease, were attacked by pleurisy 
or pneumonia, and succumbed to them. In others, the children died 
suddenly under tetanic convulsions and severe oedema; even puru- 
lent effusion in the brain was found at the autopsy. Sometimes 
the intestinal mucous membrane participates in a high degree, espe- 
cially at the commencement of desquamation, and profuse intestinal 
catarrh, or dysenteric diarrhoea, with very painful tenesmus, comes 
on. But the most frequent of all anomalous localizations is that upon 
the kidneys, by which acute Bright's dropsy is produced. This has 
already been treated of in detail on page 443. In some epidemics it 
occurs very early in the disease ; in others it is hardly observed at all. 
In the latter epidemics, in Munich, it was one of the greatest rarities, 
and did not appear even among the poorest class, where the want of 



DISEASES OF THE SKIN. 481 

all care and attention would lead us to expect it with great certainty. 
In other epidemics half, and even more, of all the patients became 
dropsical, notwithstanding the best of care and nursing ; and, although 
it cannot be denied that a judicious treatment might possibly be capa- 
ble of warding it off, still it must be confessed that the main cause is 
to be looked for in the character of the epidemic. 

Where the angina is considerable, very generally tumefaction of 
the cervical lymphatic glands, and occasionally parotitis, supervene. 
More details concerning this affection are to be found on page 115, in 
the section which treats of metastatic parotitis. From the same source 
a coryza or an otorrhoea may also become developed by the disease of 
the mucous membrane, particularly the diphtheritic form, extending 
into the nares, or, by implication of the Eustachian tubes, induce an 
otorrhoea interna, which may result in perforation of the tympanum. 

Lastly, metastases on the subcutaneous cellular tissue, with pro- 
fuse suppuration, are also observed, and in the torpid and septic form 
gangrenous bed-sores quickly come on. 

The sequelce of a grave scarlet fever are very numerous. Those 
most frequently observed are chronic serous effusions into the pleura 
or peritonasum after Bright's disease, imbecility, chorea, paralysis, deaf- 
ness, bhndness, and noma, in cachectic children improperly cared for. 

The differential diagnosis of scarlatina and measles will be given 
presently, when we speak of measles. Neither pathological anatomy, 
nor the chemical investigations of the blood, nor of the excretions, 
furnish any clew regarding the nature of scarlatina-poison. No con- 
stant morbid alterations, mth the exception of tumefaction or diphthe- 
ritis of the tonsils, are usually found in the cadaver. 

Etiology. — Scarlatina originates by contagion. It adheres strong- 
est to the scales of the integument which were thrown off during 
desquamation, and for that reason, also, does infection occur most fre- 
quently at this time, and not during the florescence of the exanthema, 
during which it is most possible to transport the disease with the pa- 
tient, and thus limit its extension. On the whole, the epoch with 
which the capacity for infection begins and terminates is not yet 
positively established. Instances are related where children infected 
others during the precursory stage, and some again where infection 
took place long after desquamation had been completed. 

The contagiousness is not equally declared in all cases ; in some 
it is so eminent that all the children of a family fall sick as soon as 
the fever has broken out in one ; in others it is so mild that the ma- 
jority of the family remain well, notwithstanding frequent intercourse. 
Stoll., Sanoood., and 3Iiquel, have performed numerous inoculations 
31 



482 DISEASES OF CHILDREN. 

Tvitli scarlatinal blood, or serum, from the miliary vesicles, and fre- 
quently succeeded in producing scarlet fever, which was as severe as, 
and even more so than, the one employed for the inoculation. If 
only an infection, and no weakening or diminished localization of the 
poison can be attained by the inoculation, then, of course, it fails 
in its object. For that purpose it is not necessary at all to resort 
to this complicated manipulation; simple contact with the scarlet- 
fever patients is all that is requisite. Children between two and 
twelve years of age are most susceptible to the contagion. Very small 
children are but rarely subject to the fever, and only become ajffected 
by it in severe epidemics. The mortality varies from two to twenty 
per cent. Some very reliable authors assert that a person may have 
scarlet-fever twice. This, however, seems to occur so very infrequently 
that there is a greater reason to assume an error in the observation — 
which, on account of the diagnostic difficulties of some cases, is very 
excusable — than to believe in the actual occurrence of such instances. 

Treatment. — In consequence of the variation of the individual 
epidemics, it is impossible to prescribe one system of treatment that 
would be applicable to all scarlatinas; moreover, this variation de- 
stroys all faith in the many remedies lauded as specifics. 

It is useless to name here the numerous prophylactic remedies, 
since none have actually proved to be such. The only rational prophy- 
laxis consists in an entire isolation of the children from all scarlatinal 
patients and all persons who come in contact with such patients. This 
isolation must last at least from five to six weeks for each patient, but 
how far and in what roundabout ways the fever may be transported by 
a third person, it is altogether impossible to say. In grave epidemics, 
in which a majority of the patients perish, it is best for the children 
to leave the city altogether, but that is frequently attended by great 
sacrifices, as the epidemics often rage for a long time and simultane- 
ously in many cities. 

The treatment of scarlatina is either attempted with specifics and 
methods, or it is simply expectant and controlled by the symptoms. 

To the specific remedies belong : carbonate of ammonia, 3 j — 3 ii, 
in a I V solution — chlorine-water, 3 j, in an 3 viii solution ; the mineral 
acids ; acetic acid, 3 ss — 3 j pro die. 

The specific methods were, and in part are still : general abstrac- 
tion of blood, emetics and aperients, and cold affusions — infrictions of 
fat, often eulogized and again forgotten, and lately urgently recom- 
mended by Sch/ieemann^ in conjunction with cooling treatment. The 
methodical cold-water treatment, it is true, has not produced the harm 
dreaded by the older physicians, but in grave epidemics it has proved 
to be totally inefficacious. This author causes the entu'e body of the 



DISEASES OF THE SKIN. 483 

patients, with the exception of the head, to be rubbed with lard, from 
the first day on, for three weeks, morning, noon, and evening ; in the 
fourth week once a da}^ only. With this, the temperature of the room 
should not be above 60° F. ; the bed protected from cold during the 
eruption only, coohng drinks so long as the fever lasts, and internally 
no remedies are to be given. ^cJi7ieeraann very justly lays great 
stress upon thorough and often-repeated ventilation, but carries his 
cooling treatment somewhat too far when he advises the temperature 
of the room to be reduced to between 57° and 59°, and the windows 
of the sick-room to be kept open three hours every day. 

It need hardly be stated that these specific remedies and specific 
methods have no specific effect whatever, and all of them, in grave 
epidemics, are set at defiance by the virulence of the scarlatinal poi- 
son. In milder epidemics, those remedies are best which torture the 
children least, and husband their enfeebled strength. Of all the reme- 
dies, the preference should therefore be given to a diluted mineral 
acid ; of all the methods, to a moderate infriction of fat. 

The expectant treatment of the symptoms is limited to the removal 
of the patient from all noxious agents, and to the palliation of the 
particularly grave symptoms. 

Proper ventilation of the sick-room is always the best guarantee 
of a favorable course. This is carried out to the greatest perfection 
when two adjoining rooms are devoted to the use of the patient, and 
he spends half the day in one, and half the day in the other room. 
The temperature of the room should be 60° F., so long as the exan- 
thema lasts ; after it has grown pale, or if it did not become properly 
developed, the temperature should rather be raised than diminished. 
The garments of the child and bedclothes should be so arranged that 
it is not kept in a constant state of perspiration, but yet so as not to 
be chilled. The diet, so long as the fever lasts, should be antiphlo- 
gistic ; where constipation exists, a mild aperient, of some composition 
which the child will readily take, should be employed ; and, where there 
is a disposition to diarrhoea, constipating soups and mucilaginous 
drinks should be given. "When the fever is gone, such a scanty diet 
will vastly retard convalescence ; and no apprehension need be enter- 
tained in regard to the use of mild, easily-digested, plain articles of food. 

When desquamation has been in full progress for several days, its 
completion may be accelerated by a few baths, given with great cau- 
tion, after which the patient may be gradually taken out into the free 
air. In order to guard against all possible reproach, it is well not to 
allow the patients to go out of the house for six weeks ; but this, of 
course, cannot be accomplished among the lower classes, and where 
the care of the children is neglected. In normal scarlatina anj^ simple 



484" DISEASES OF CHILDREN. 

slightly acidulous, saline, or mucilaginous drinks may be given inter- 
nally as a vehicle for amnion, carb. 3 ss, daily, in cases where the ex- 
anthema is imperfectly developed. In the treatment of symptoms, it 
is well to observe that, in some of the gravest and most threatening 
ones, neither hasty nor too energetic measures should be adojDted. 
The violent fever before the eruption may tempt us to resort to the 
abstraction of blood, or to the use of calomel ; but we should always 
bear in mind that the course of the disease is hkely to be retarded 
by these measures, while the fever is not made to disappear. 

Where the eruption is very much retarded, an attempt should be 
made, by the aid of sinapisms, sponging of the body with warm water, 
vinegar, or lye, to hasten its progress. "\^Tiere the rash is already de- 
veloped, infriction of lard is the most advantageous treatment, by 
which the annopng itching is palliated, and the protection against any 
sudden cooling of the skin is effected. 

Threatening cerebral symptoms, delirium, stupor, or coma, are ma- 
terially relieved by very cold affusions of the closely-shorn head, which 
must be repeated every hour. In the torpid, septic form, the powers 
of the system should be sustained by quinine, camphor, wine, musk, 
and castoreum. 

In mahgnant diphtheritic anginas an energetic local treatment, by 
the application of concentrated muriatic acid or a solution of nitrate 
of silver, would be very beneficial. But the prostration of the patients 
and their resistance form great obstacles to this part of the treatment. 
For the same reason it is but seldom possible to employ gargles, and 
we have therefore to Hmit ourselves to the administration of such in- 
ternal remedies as are regarded as specifics. The best of these are 
carbonate of soda and chlorate of potassa ; the first has a really fa- 
vorable effect in cleaning the mucous membrane, the second destroys 
the putrid odor. Both are given separately, dissolved in water, a 
drachm of each daily. 

The treatment of albuminuria has already been spoken of on a 
former occasion, likewise that of parotitis after scarlatina. Intestinal 
catarrh must be reheved as rapidly as possible by the aid of opium, 
and mucilaginous and astringent remedies. Paralysis and convulsions 
call for the treatment prescribed for these affections on pages 394 and 
388. Consecutive inflammations of the joints and serous effusions 
improve by the aid of warm anodyne cataplasms and resolvents. 

(2.) Measles {3forhilU). — By measles is meant an acute conta- 
gious eruption of the skin, which manifests itself by small, round, red 
spots, attended by catarrhal phenomena, and terminates by a furfura- 
ceous desquamation of the epidermis. 

Since the individual epidemics of nieasles, just like epidemics of 



DISEASES OF THE SKIN. 485 

scarlet ferer, present marked variations, and are very different in their 
course, their danger, and in their sequelae, it will be more advanta- 
geous to first give a description of a normal case, and then to speak of 
its modifications. 

A.—jS^OBMAL MOBBILLI. 

(1), A stadium of prodromata; (2), a stadium of eruption; (3), a 
stadium of florescence ; and, (4), a stadium of desquamation, may be 
distinguished with tolerable precision. 

1.) The Peodeomata Stage {Stadium Invasiooiis). — In robust 
children and mild ei3idemics, the prodromes are not so violent as to 
cause the children to take to bed, or to present any signs of a serious 
disease. The most common difficulties are : catarrh of the nose and 
sneezing, with consecutive swelling of the nasal mucous membrane, 
reddened conjunctivae, lachrymation, slight blepharitis, intolerance of 
light, hoarseness, and a dry, barking cough. The general symptoms 
are reduced to languor, prostration, anorexia, slightly-increased tem- 
perature of the skin, thirst, and vespertine exacerbations, which, in 
nervous children, may attain to delirium at night. The tongue is 
coated, taste bad, and pressure upon the stomach painful. Occasion- 
ally the febrile symptoms decline somewhat after a profuse epistaxis. 

All these symptoms increase in intensity from day to day, and 
usually manifest themselves only a few days after infection occurred. 

According to Kerschensteiner'' s accurate observations, a period of 
from ten to twelve days always intervenes between the day that the first 
child in a family is attacked by measles and the day the other children 
to whom he gives the disease fall sick. Panum^ who under extremely 
favorable circumstances watched an epidemic of measles on the Faroe 
Islands, assurnes a stadium of precisely fourteen days. But, since we 
know that the exanthema also infects as soon as it has appeared upon 
the skin, it may therefore be assumed with great probabihty that 
the children who subsequently fell sick carried about them the mor- 
bilH poison for from ten to fourteen days. The prodromes do not 
come on till from three to five days before the actual breaking out 
of the exanthema, and hence it is clear that the morbilli poison re- 
mains perfectly inert for the first six or seven days after its reception. 

2.) Stadium Eeuptionis. — The exanthema first appears on the 
face, cheeks, or dorsum of the nose, and from these places creeps over 
the neck to the trunk, on the upper, and lastly on the lower extremi- 
ties. In previously healthy children, the eruption is completed in 
twelve hours ; in general, however, it progresses slower than that of 
scarlet fever. 

The exanthema begins with faint red, small round spots, of the 



j^So DISEASES OE CHILDREX. 

size of a lentil. These constantly grow redder — coalesce, wlien they 
stand close together, into irregular figures ; still there is always some 
intervening normal integument. As they increase in redness, they 
also grow in height, and become elevated over the level of the skin, 
and, when they have attained to their utmost height, turn somewhat 
yellowish, but never form vesicles. Similarly red, elevated spots 
of the skin are present in genuine variola, which last for several 
hours, and cannot be distinguished from those of measles. But the 
general symptoms in these two exanthemata differ vastly, and genuine 
variola is hardly ever met with nowadays in civilized countries, on 
account of compulsory vaccination. 

The red, elevated spots feel rougher than the normal integument, 
and the hand in passing over them perceives a very peculiar feel of 
unequal hardness. The mucous membrane of the mouth, in fact, also 
displays some unequally red spots, but here the exanthema is by far 
less distiuct than in scarlathia. 

The general sjnnptoms reach their climax with the breaking out 
of the fever ; most of the jDatients are delirious, very restless, and mis- 
lead one to suspect a very grave disease. The bowels are constipated ; 
the urine is dark red, rich in uric acid and urates. 

3.) Stadium Floeescextl^. — Measles are visible on the skin for 
four days ; the fever and mucous-membrane symptoms continue in 
a moderate degree, but the general disturbances visibly decline. 
The eruption fades in the same order of procession as it appeared, 
namely, first in the face, next on the trunk, and lastly on the ex- 
tremities. The greatest amount of tension and swelling is seen on 
the second day after the eruption ; by the fourth these have subsided. 
The integniment sometimes becomes yellowish before it returns to its 
normal color, and by the fourth day only indistinct traces of the 
faded exanthema are seen. The conjunctivitis and nasal catarrh also 
improve, while the bronchitis, on account of the great extent of the 
ramifications of the respiratory mucous membrane, often continues for 
a long time, and even in a severer degree than at the beginning. Here 
the expectoration is very considerable. As soon as the exanthema 
has faded on the whole body, the skin begins to desquamate, and the 
process is known as the 

4.) Stage oe Desquamatiox {Stadium Desquamatiojiis). — 
Wherever the eruption occurred, there the epidermis is thrown off; 
not, however, as in scarlatina, in large laminae, but always only in 
very small scales, which often lie upon the skin like a white dust, and 
is best seen when it is rubbed with a black cloth. The more abun- 
dant the exanthema, the more whitened and dusty will the cloth 
become. The mucous membrane of the nose and eyes is now per- 



DISEASES OF THE SKIN. 487 

fectly free, but that of tlie bronchi, even in normal measles, discharges 
a considerable quantity of secretion for several weeks by coughing. 

The general condition improves remarkably quickly, so that it is 
scarcely possible to keep the child in bed for more than three or four 
days after the exanthema has faded. With the exception of the 
cough, that annoys them but little, these patients are now entirely 
free from all morbid derangements ; they sleep well, their appetite is 
excellent, the stools and urine are normal, and the strength, which 
had been considerably reduced by the disease, is recovered in a few 
days. Tliis is the picture of a normal case of measles, as seen, in any 
moderate epidemic, in an otherwise healthy child. 

B.— VARIATIOm AND SEQUELS. 

These are (1), dei^iations in reference to the exanthema; (2), in 
reference to the mucous membranes; (3), in reference to the general 
affection; and (4), a list of frequent and malignant sequelae. 

1.) Modification^ of the Exanthema. — The exanthema does 
not always appear in the order above described. In the nervous, 
irritable child, especially when covered with superfluous clothing, it 
breaks out as early as the second day after the appearance of the pro- 
dromata, and often departs from its usual order of progress. It may 
appear first on the extremities instead of the face : the small, red dots 
may coalesce in some places, and then it becomes difficult to distin- 
guish this eruption from that of scarlatina. These larger spots, 
however, are never diffused over the whole body, and, besides, they 
always possess points sufficiently characteristic of measles not to be 
confounded. An eruption of vesicles, the so-called miliaries, also 
sometimes appears in the course of measles — still much more infre- 
quently than in scarlatina. When it does occur, however, the des- 
quamation is always more abundant, and larger laminae are cast off. 
In malignant epidemics, the exanthemata become bluish, and do not 
entirely disappear, but leave behind them ecchymosis, and are com- 
plicated with malignant affections of the mucous membranes. 

The florescence may be variable in duration. Sometimes it lasts 
only for two or three days, but it may also be seen for five or six days, 
and it is even reported to have totally disappeared and returned again 
in a few days with renewed fever. 

2.) Participation of the Mijcofs Membeanes. — The mucous 
membranes are much more extensively and intensively affected in 
morbilli than in scarlatina, and danger is more frequently to be appre- 
hended from that source than from the morbilli poison. 

The ordinary conjunctivitis may become a pernicious blennorrhoDa, 
v/ith severe cedema of the lids. 



488 DISEASES OF CHILDREN. 

The nasal catarrh may give rise to such an irritation of the mucous 
membrane that incessant sneezing, marked congestion of the head, 
and exhaustion, finally ensue. 

The inflammation of the palate and glottis sometimes occasions 
such an unceasing irritation and coughing as to cause true paroxysms, 
not unlike whooping-cough, accompanied with vomiting and haemor- 
rhage. 

In malignant epidemics, it becomes more than simple congestion 
and catarrh of the mucous membranes. Diphtheritic membranes soon 
form, by which perforation of the cornea, and gangrene of the lids, 
fetid coryza, and salivation, may result. And, when the mouth and 
larynx are invaded, salivation and urgent croupous symptoms come on. 

Lobar and lobular pneumonia are extremely frequent in measles, 
and these in particular destroy a great many children under one year 
of age. 

The intestinal canal is much less frequently implicated in this dis- 
ease than the respiratory organs ; still, diarrhoea, of a very pernicious 
character, also occurs sometimes. The uropoetic system, quite differ- 
ent from scarlatina, wherein nephritis and albuminuria are the most 
frequent complications, rarely becomes affected in measles. In girls, 
diphtheritis of the vagina occasionally occurs, which usually eventuates 
in gangrene of the labia and death. 

3.) Character of the Fever. — Same as in scarlatina: (1), an 
erethetic; (2), a synochal; (3), a torpid, and (4), a septic character, 
which may manifest itself in whole epidemics as well as in individual 
constitutions. Every thing that has been said upon this point, as re- 
lates to scarlatina, is equally applicable to measles. 

The erethetic form is the usual one, and has been described under 
" A.—N'ormal ^forhillV None of its symptoms become grave ; the erup- 
tion comes and goes at the right time, and is of moderate intensity ; the 
affections of the mucous membrane, the fever, and the cerebral symp- 
toms, are within proper bounds, and there follow no sequelae of import. 

"When the vascular excitement becomes very considerable, the 
synochal inflammatory character is assumed. In most instances it is 
ushered in by a violent precursory stage. The inflammatory affections 
of the mucous membranes are very severe, the skin becomes burning 
hot, and the whole body instantly dotted with dark-red, prominent 
spots. The cerebral symptoms look very threatening ; wild delirium 
alternates with profound soporific sleep. The intensely-developed ex- 
anthema, in most instances, lasts longer than four days, and may be 
distinctly perceived on the fifth and sixth day. The desquamation, 
corresponding to the preceding intense cutaneous congestion, is very 
marked. Consecutive affections are frequently observed. 



DISEASES OF THE SKIN. 489 

In malignant epidemics, and in cacliectic and especially scrofu- 
lous children, the torpid character of the fever is most marked and 
frequent. Here the precursory stage is protracted by grave symp- 
toms, and an extraordinarily rapid exhaustion is noticeable from the 
very first. The patients complain of vertigo and pains in the limbs, and 
are fearfully anxious, restless, and sleepless. The pulse is very much 
accelerated, and small and easy to compress, which, with vomiting, 
profuse diarrhoea, and croup-like paroxysms of coughing, present a list 
of symptoms wliich, even before the eruption of the exanthema, give 
reason for a very unfavorable prognosis. 

The exanthema itself, in this form, seldom appears at the right 
time, properly developed. It disappears again directly after its ap- 
pearance, is only seen on some parts of the body, and never attains 
the usual vivid-red color. 

The mucous membranes are very much disposed to diphtheritic in- 
flammation. Profuse diarrhoea, malignant bifonchitis, croup, and sim- 
ple enervation, without any demonstrable morbid lesions, sometimes 
terminate life. 

An eruption of measles, presenting the highest grade of this char- 
acter, constitutes the sep^^c or putrid variety. The eruption appears 
irregularly, and soon becomes complicated with ecchymosis. Coma and 
syncope are the most prominent cerebral symptoms. The diphtheritic 
mucous membrane is prone to gangrenous action, and in girls this soon 
extends to the vulva. Profuse nasal and intestinal haemorrhages may 
soon induce a high degree of ansemia, or even scorbutic condition. 

This putrid or torpid character is by no means always present from 
the commencement. It also happens that measles, wliich at first ap- 
peared as synochal, alter their character entirely, in the course of a 
few days, to that of the putrid variety, and, for this reason, this dis- 
tinction of difi"erent forms has less accurate scientific than practical 
therapeutic value. 

4.) Sequeljs. — The most frequent, and, at the same time, the 
most serious sequel of measles, is tuberculosis. Sometimes it devel- 
ops very rapidly and intensely as miliary tuberculosis, so that the pa- 
tients never recover enough to leave the bed, but continue to sufi'er from 
fever, and to cough and emaciate from the time the exanthema disap- 
peared. Generally, however, a lengthy interval is observed between 
the disappearance of the eruption and the appearance of the first tuber- 
culous symptoms. These children get up again, are free from fever, 
have good appetite, and the measles is forgotten. A slight bronchitis, 
however, has remained, and persists, in defiance of the best nursing, 
imiform temperature, and the numerous expectorants. Yery gradually, 
vespertine exacerbations are noticed, followed by general indisposition. 



490 DISEASES OF CHILDREN". 

loss of spirits and strength, and Trith this the cough increases in 
severity. The emaciation becomes more and more marked, the 
tuberculous phenomena are soon physically demonstrable, and, in most 
instances, rapidly advance to a fatal termination. Their progress is 
rarely arrested, but, when this does occur, such children will for years 
be prone to bronchitis, and will often experience new tuberculous 
attacks. A more detailed description of the symptoms belonging to 
this condition is to be found in the section on pulmonary tuberculosis, 
page 313. 

Otorrhcea is another consecutive disease, and, in most instances, is 
complicated with tuberculosis, and often resists the astringent treat- 
ment for many months. Impetigo and eczema of the face, and of the 
scalp, especially behind the ears, are also very common sequelae. In 
scrofulous children, chronic inflammation of the eyes, particularly 
blepharitis, remains for a long time. 

Sometimes the diphtheria occasions very protracted hoarseness, or 
a croup, which, however, in general, affords a somewhat more favora- 
ble prognosis than pure fibnnous crouj^. 

Intestinal catarrhs likewise occur, seldom, however, become colh- 
quative, and are quickly arrested by a judicious diet and proper astrin- 
gents. 

In badly-nourished, cachectic children, noma also occasionally super- 
venes. 

The remaining lesions represented as sequelae, such as hydrothorax, 
ascites, pericarditis, meningitis, etc., occur so rarely, that one is led 
to doubt whether he should ascribe any direct connection between 
them and measles. 

At the autopsy, lobar and lobular pneumonia, dij^htheria of the 
mouth and its effects, intestinal catarrh, gangrene of the vulva, etc., 
are found, but neither in the blood, nor in any organ, can any altera- 
tion be discovered that will furnish a clew to the nature of measles. 

Diagnosis. — Measles may be confounded with scarlatina and ery- 
thema. Yery many new-born children, and infants a few weeks old, 
are attacked by a fine punctated erythema, diffused all over the body, 
which differs in no respect from the eruption of measles. This is, 
most probably, produced by mechanical causes ; the young, delicate 
cuticle, not yet sufficiently accustomed to the contact of the air, baths, 
and clothing, becomes irritated, and its papillge inflamed and en- 
larged. This exanthema, in most cases, lasts for several days, vanishes, 
returns occasionally, but ordinarily is not complicated with catarrhal 
symptoms. If these accidentally happen to be present, the whole 
affection will not run such an exactly rhythmical course, and is not 
ushered in by such violent fever as ushers in measles. Moreover, 



DISEASES OF THE SKIN. 



491 



ervtliema of the new-born child occurs without any contagion. This is 
particularly instructive when taken in connection with the circumstances 
that new-born children are far less susceptible to the morbilli con- 
tagion than older ones, and usually escape the disease, although it 
may be in the same house with them. 

The differential diagnosis between measles and scarlet fever is oc- 
casionally attended by difficulties, especially when both diseases pre- 
vail simultaneously in the same locality. It may, therefore, prove 
useful if the principal symptoms and distinctive characteristics of both 
exanthemata are once more enumerated side by side. 



DITFERENTIAL DIAGNOSIS. 



MOEBILLI. 

The precursory stage lasts from 
three to four days. 

- The most constant of the precur- 
sory symptoms are : conjunctivitis, in- 
tolerance of light, nasal and bronchial 
catarrh, sneezing, snuffling, hoarse- 
ness, coughing. Trequency of the 
pulse and the temperature of the skin 
but slightly augmented. 

The exanthema consists of small, 
roundish, red spots, slightly elevated 
above the skin, and only on very few 
places coalesce and form larger, un- 
equally-elevated patches. It breaks 
out first on the face. 

As soon as the rash has broken 
out, all the critical general symptoms 
disappear. 

The exanthema of measles, in gen- 
eral, lasts somewhat longer than that 
of scarlatina. On the fourth day it is 
very distinctly seen ; on the fifth and 
sixth it is often still present, though 
less distinct. 

Desquamation in a fine, white 
powder. 

Sequelae : tuberculosis, bronchitis, 
inflammations of the eye, croup, and 
pneumonia. 



SCAELATmA. 

The exanthema breaks out on the 
second or third day. 

The catarrhal symptoms are almost 
totally absent. On the other hand, 
marked dysphagia is present, due to 
swelling of the tonsils. The fever is 
intense before the eruption of the ex- 
anthema. 

The eruption, in most instances, 
covers the entire body, or at least 
covers large, flat, irregular patches. 
It is most intense on the parts of the 
body of the child which are covered. 
It begins on the neck, and usually 
spares the face. 

Fever and angina continue un- 
abated during the florescence. 

The exanthema of scarlet fever, as 
a rule, is completely gone on the fourth 
day. 



Desquamation in large laminse. 

Sequelae : nephritis, dropsy, paro- 
titis, and otorrhoea. 



Notwithstanding these differential cardinal points, the diagnosis 
in some cases remains doubtful, and for this reason also totall}' un- 



492 DISEASES OF CHILDREN. 

authorized names have been invented, such as scarlatina morbillosa, 
and morbiUi scarlatinosa. 

The prognosis^ as given in most cases, is too unfavorable in scarla- 
tina, and too favorable in measles, for all the apparently recovered 
patients should not be regarded as actually cured, as tuberculosis, 
which very often develops after measles, and goes on unchecked, car- 
ries off many; thus, if the observation were only conducted far 
enough, it would be seen that the ratio of mortality is not so very 
favorable after all. 

To repeat, very few children die during the florescence or imme- 
diately after the desquamation, especially if they have already passed 
the first year, but then the subsequent tuberculosis always attacks 
several per cent, of all ages. 

Etiology. — Measles is contagious to a high degree, so that by us 
in Munich almost every jDerson who is not yet impregnated with the 
virus is attacked by it. The contagion is extremely subtile, and no 
direct contact with morbilli patients is at all necessary for an infection. 
Occasionally it is very easy to prove its having been transmitted by a 
third person. 

Most of the attempts at vaccination with the blood of morbilli joa- 
tients, whose exanthema was at the stage of florescence, are said to 
have taken effect, and tolerably benign, normal measles appeared be- 
tween the seventh and tenth day. But, as the process was not there- 
by localized, and the course being about the same as when the children 
have been accidentally infected, these inoculations have therefore no 
practical value whatever. 

The contagion of morbilli does not prevail to the exclusion of all 
other infections. Thus varicella, small-pox, and intermittent-fever 
patients, have been seen to be affected with it. When scabious pa- 
tients get measles the scabies usually heals spontaneously and remark- 
ably quickly ; due, perhaps, to the itch animalcule perishing by the 
contagion or the material alteration of the cutis. 

Finally, the remarkable connection between measles and whooping- 
cough is yet to be mentioned. It has been observed that the conta- 
gion of one relieves the other, measles being particularly often followed 
by whooping-cough, and a certain relation between the two affections 
might readily be assumed to exist. 

Treatment. — We have no specific remedy for the contagion of 
measles. All those measures hitherto suggested have not stood the 
test. Inoculation, as already stated, is not practicable, for, that which 
is obtained with much labor, the children usually acquire themselves, 
namely, normal measles. Isolation of the patients affected with 
measles, and all persons who have any intercourse ^vith them, is the 



DISEASES OF THE SKIN. 493 

only sure means of preventing infection. But, during the jDrevalence 
of an epidemic, this can only be done by a change of place, and is 
principally indicated in pronounced cases of tuberculosis, in Avhich 
measles invariably induce a rapid advance of the cachexia. 

The simple and regular measles require an entirely expectant 
treatment. Energetic measures, such as abstraction of blood, tartar 
emetic, or laxatives, in many instances impede the uniform course, 
without removing the danger or threatening symptoms against which 
they have been employed. 

The best protection against an irregular course and against sequelae 
is a uniform, tolerably high temperature of the room, 65° F., so long 
as the children are in bed, 67° F. when they are about to get up. 
The patient should not leave the bed as long as any trace of the erup- 
tion is still to be seen, and should be confined to his room for at least 
two weeks, and in unfavorable seasons of the year for a still longer 
time, after the eruption has totally disappeared. 

Heavy featlier beds, under which, according to the old style, pa- 
tients were kept covered up to the chin, induce too much perspiration, 
rendering them liable to take cold with all the greater certainty. 
Horse-hair mattresses and plain woollen blankets answer every purpose. 
It is of the utmost imjDortance to ventilate the room thoroughly, and 
that can be best accomplished when the patient has two adjoining 
rooms for use. Children reared in a cleanly manner find it very 
disagreeable to pass several days without having their faces and hands 
washed, a management which is still prescribed by many older physi- 
cians. All the morbilli patients that I have treated were washed, face 
and hands, twice a day with lukewarm water, and I have never per- 
ceived the least bad effects from this practice. This useless torture, 
the deprivation of washing-water, should therefore be totally dis- 
carded. 

The diet should be absolutely antifebrile, so long as any traces of 
fever are perceptible. To forbid food when the appetite has returned 
is cruel, and only retards the convalescence. Children never make 
themselves sick by eating bland, unsweetened nutriments, such as 
milk, soup, and wheat-bread. Where there is a disposition to diar- 
rhoea, constipating food must be allowed ; but, where constipation ex- 
ists, mildly-opening nutriments and drinks should be given. 

The treatment of irregular measles, of complications, and of se- 
quelae, is a problematical one, for no really marked effects have been 
observed from almost all the remedies recommended. 

Measles with marked synochal, inflammatory character, tolerate 
very well 3j — 3ij of nitre; serious head-symptoms in very robust, 



49i DISEASES OF CHILDREN. 

older cliildren are very quickly subdued by a few leeches. In the 
torjDid, nervous form, mineral acids, cinchona, and wine, are indicated. 
Severe cough is palliated by narcotics, belladonna, bitter-almond- 
water, or opium. Grave cerebral symptoms call for cold ajQPusions of 
the closely-shorn head. Exanthemata that have disappeared too rap- 
idly, or been retarded, are best treated by counter-irritants, sinapisms, 
and the like. Clysters with diluted \TLnegar have also been recom- 
mended for that purpose. 

Severe diarrhoea must, in all cases, be controlled by opium and 
astringents ; slight diarrhoea, in other^vise well-nourished children, ex- 
ercises a favorable influence upon the cerebral symptoms. 

The diphtheritic affections of the mucous membranes improve un- 
der the internal administration of carbonate of ^ootassa, in large doses, 
at least 3 ij — 3 iij joro die, and locally, so far as the parts can be 
reached, they should be pencilled with a solution of nitrate of silver. 
For real sepsis, profuse hsemorrhages from the mucous membrane, gan- 
grenous diphtheritis, and ecchymosis of the cutis, the utmost tonic 
and stimulating measures, with large doses of wine, quinine, musk, 
and naphtha, must be emiployed. "Washing the body with chlorine- 
water has also been recommended. I cannot, however, conceal the 
fact that, in real septic cases, all these methods of treatment have al- 
ways failed me. 

Pulmonary tuberculosis, which comparatively often develops after 
measles, may stop, like that originating spontaneously. Large doses 
of quinine — from two to four grains given at one time every other 
day — exercise a favorable influence upon its course. A year's con- 
stant use of cod-liver oil strengthens the nutrition, and perhaps, also, 
guards the organism against new tuberculous attacks. Country air, 
sea-baths, and a rational inuring, are the best prophylactics against 
the progress of tuberculous affections. 

(3.) Rubeola {Rotheln). — There is scarcely another disease upon 
which the views of authors differ so vastly as upon r-ubeola. Some 
look upon it as a modified scarlatina, others as measles, and still others 
as an amalgamation of both. Erythema, urticaria, even tjrphous and 
cholera exanthema, have been described as rubeola ; and the confu- 
sion finally became so inextricable that later writers have denied the 
existence of the disease entu-ely, and ascribed all obscure and doubt- 
ful cases to some of the above-mentioned affections. This later \'iew 
I also entertained till the spring of 1865, when I became better in- 
formed. At that time eleven persons — three adults and eight chil- 
dren, from six months to eight years of age — came under my care. 
Without any distinct prodromata presented, they all had an eruption 
of exanthema, which differed in no respect from that of measles. My 



DISEASES OF THE SKIN. 495 

friend Lindwurm at tlie same time liad five additional cases to treat, 
and, upon inquiries, several physicians in Munich recollected having 
seen at that time a peculiar fever, " a febrile urticaria with a measles- 
like exanthema." Neither before nor since that time have I met with 
this eruption. It is proper to remark that this disease was not imme- 
diately preceded nor soon followed by any epidemics of measles or 
scarlet fever. The phenomena presented by this affection are sketched 
by Kostlin^ of Stuttgart, in the following manner : In the winter of 
1860-'61 an extensive epidemic of rubeola prevailed in that city dur- 
ing five or six months. The exanthema was not smooth, but slight- 
ly papulous, had a yellowish tint, not confluent, but formed short 
or long, serpentine, seldom straight lines, which, in most instances, 
covered the entire body. The exanthema was not infrequently ac- 
companied by considerable itching of the skin. The eruption, as a 
rule, disappeared in two or three days, sometimes even sooner. In 
most instances it appeared, and ran its course without the least catar- 
rhal symptoms, and without fever. Though mild, this exanthema 
was extremely infectious, infecting whole families. Several children 
were even twice attacked during the same epidemic. It appeared at 
the same time in various other cities and towns in Wurtemberg. 

Symptonis. — The symptoms which I have observed may be com- 
prised in a few words. The exanthema differs in no respect from that 
of morbilli ; small round spots of the size of lentils cover the entire 
body, occasioning, in most instances, a considerable amount of itching. 
At some places these spots stand so closely together that they coalesce 
and form irregular figures. They also rise somewhat above the level of 
the normal integument, and the finger, in lightly passing over them, 
perceives an unequal hardness. The eruption differs, however, very 
much from measles in respect to its duration. It completely disap- 
pears by the end of the first, or, at the longest, by the end of the sec- 
ond day, and the desquamation that succeeds it is very insignificant, 
barely noticeable. The same is true of the catarrhal symptoms. Al- 
though, along with an intense eruption of the exanthema on the face, 
the eyelids swell up, and the conjunctivse are somewhat injected, still 
bronchial catarrh is uniformly absent, which, in morbilli, on the con- 
trary, is a pathognomonic, never-failing symptom. Scarcely any pre- 
cursory stage was noticeable in most of our cases, and the indistinct 
febrile phenomena disappeared so completely after the first day, with 
the fading of the exanthema which soon followed, that by the third 
day it was totally impossible to keep the children in bed, and they 
quickly recovered without the first sequela. 

Treatment. — This is purely expectant. Internally, dilute acids, 
and, externally, cold ablutions, to relieve the intolerable itching of 



496 DISEASES OF CHILDREN. 

the skin, were the only remedial means employed in tliis most harm- 
less of all acute febrile exanthemata. 

(4.) Variola, Smaxl-pox. — Genuine human small-pox is the most 
positively declared of all acute exanthemata. It, however, occurs com- 
paratively rarely, on account of the compulsory vaccination that is in 
force at present in almost all civilized countries, and in time will 
probably be totally supplanted by the milder forms of variolois, also 
called variola modificata, and by varicella. 

By variola is understood a febrile, contagious, pustular, eruptive dis- 
ease, whose course is uniform. It may be divided into several periods. 

Symptoms. — Three distinct stages are distinguished. (1.) The 
stage of incubation and of prodromorum; (2), that of florescence of 
the exanthema; and (3), that of desiccation. 

(1.) Stadium Incuhationis et Prodromorum. — The period from 
the recejDtion of the contagion to the eruption of the exanthema fluc- 
tuates between eight and fourteen days. The first few days of this 
period usually pass without any signs manifesting themselves; but 
in the last three days preceding the eruption severe symptoms are 
observed. I shall limit myself here to a delineation of the prodromata, 
as they occur in a child under one year, taking it for granted that a 
knowledge of the course of small-pox in adults has already been ac- 
quired from other sources. Small-pox now occurs only in very young 
children, for vaccinated persons are totally exempt from it, and by us, 
in Germany, vaccination is usually performed before the end of the 
first year. 

If they have been infected a few daj^s previously with genuine or 
modified variola poison, we observe slight gastric symptoms, such as 
loss of appetite, coated tongue, vomiting, and constipation. There 
v/ill also be observed excitement of the vascular and nervous system, 
hot skin, frequent pulse, great restlessness alternating with stupor, 
starting up from sleep with an outcry, gnashing of the teeth, convul- 
sions, and occasionally syncope, with rapid collapses. All these symp- 
toms, which certainly have nothing characteristic about them — for the 
subjective pain in the back and loins, so constant and marked a symp- 
tom in adults, is not available in infants who do not speak — become 
aggravated throughout the next three days, regular exacerbations 
come on toward the evening, till, finally, the exanthema breaks out. 

(2.) Stadium Eruptionis et Florescentioe. — The first signs of the 
eruption are seen on the face ; thence it spreads upon the trunk, and 
the upper, and lastly upon the lower extremities. The eruption is 
completed in from twenty-four to forty-eight hours. 

The small-pox pustule has the following history, viz. : a red, 
slightly-elevated spot is first perceptible upon the skin, differing in no 



DISEASES OF THE SKIN. 497 

respect from the exantliema of measles. In the centre of this red 
spot a small tubercle develops, and upon this tubercle a still smaller 
vesicle appears, which enlarges very rapidly, so that on the second day 
it has reached the size of a pin's head ; on the third, that of a lentil ; 
and finally, the primary red point is transformed into a tense, little 
blister, of the size of a split pea, with a central depression. 

These originally red points do not all go through this metamor- 
phosis ; a gTcat many of them never become vesicles, but disappear 
entirely in a few days, especially those on the lower extremities. On 
the feet, in particular, the eruption is feebler than on any other part 
of the body. 

The course of variola, as regards the form and duration of the ex- 
anthema, is precisely the same in children as in adults. 

^^len the exanthema is not excessively diffused over the whole 
body, the general symptoms will subside materially after it has made 
its appearance. The great restlessness and delirium vanish, the pulse 
becomes slower and softer, the breathing more regular, but the 
specific variola odor is more marked after the eruption than before. 
Where the eruption on the mucous membrane of the eyes, nose, 
mouth, etc., is very abundant, no mitigation in the vascular and ner- 
vous excitement will be noticeable, for the severe pain induced by the 
process prevents the patients from becoming tranquil. 

On the sixth day after the eruption, or on the ninth from the in- 
vasion, the suppurative fever — febris secundaria — appears also in chil- 
dren. The inflammatory areolae around the vesicles become enlarged, 
the face swells so as to totally disfigure the patient, the skin again 
becomes hot, and such an intolerable itching supervenes that the 
child will scratch open the pustules, notwithstanding all the precau- 
tions that may be takeii to prevent it. Thus it finally comes to the — 

(3.) Stadium Exsiccationis. — It does not begin at once on the 
whole body; the pustules burst and dry up in the same order in 
which they appeared : thus, first on the face, next on the neck, on 
the wrists, on the trunk, and lastly on the lower extremities. Every 
,pustule is nearly dried up by the ninth day after its appearance, or, 
if we include the two or three days of the prodromatory stage, on 
the eleventh or twelfth day of the disease all the pustules will have 
commenced to desiccate. Spontaneous bursting, or simple drying up 
without bursting of the pustules, hardly ever takes place in small 
children, for they cannot refrain from palliating the terrible itching 
by scratching or rubbing. 

Thus brown thick crusts form upon the whole body, especially on 
the face. If left to themselves, these crusts will fall off in from four 
to five days, and leave behind a cicatrix covered with new epidermis, 
32 



498 DISEASES OF CHILDREN. 

which the patients frequently scratch off. Small-pox cicatrices have 
the same formation in children as in adults ; but, as the cutis in the 
former is more delicate and thiner, the destruction is therefore more 
conspicuous, and the inequalities, which at first appeared very marked, 
become less unequal in the course of years. 

During this period the pustules in the mouth become converted 
into flat superficial ulcers, and induce an augmented mucus and sali- 
vary secretion. The secondary fever disappears with the desiccation, 
the apjjetite returns, and the recovery progresses rapidly. Occasion- 
ally the nails are cast off. 

The prognosis, in children under one year of age, is extremely 
unfavorable, for nearly sixty per cent, perish. 

The principal danger to small children is, (1), from a violent pro- 
dromatory stage, where profound stupor or convulsions endanger life ; 
and (2), from the secondary fever, which may assume a tjrphous or 
septic character. 

The quantitative and qualitative variations are the same as in 
adults. Here also we have variola discretae, cohserentes, corjTubosoe, 
and confluentes ; in qualitative regard, variolas crystallinige, siliquosse, 
depressge, cruentae, gangraenosae, etc. 

The most frequent complications are : laryngitis, pleurisy, menin- 
gitis, intestinal catarrh, serious diseases of the eye, which frequently 
lead to phthisis bulbi, otorrhcea, and gangrene of the scrotum. 

The most frequent sequelce deserving to be mentioned are : furun- 
culosis, abscesses of the cellular tissue, pyaemia, inflammations of the 
joints, necrosis of the bones, and, what is very remarkable in small 
children, scrofula in all its forms and localizations. The mortality in 
consequence of small-pox, in children under one year of age, is very 
great, for, as has been stated, barely forty per cent, recover. 

Etiology. — Small-pox is contagious to a high degree, and, in fact, 
also infectious through the atmosphere, is communicated by contact 
and by inoculation. It is most infectious during the suppurative and 
desiccating stages. But the most important point in practice is that 
genuine small-pox generates small-pox in not only the unvaccinated* 
children, hut that occasionally the inere contact with varioloid^ and 
even with very mild varicella^ may produce the genuine human 
variola in an unvaccinated child. 

Treatment.* — A- prophylactic treatment is spoken of in many dis- 

* As small-pox, unfortunately, is not so rarely met with in this country as it ap- 
pears to be where the author has made his observations, we deem it proper to append 
some remarks in regard to its pathology and treatment. At the post-mortem exami- 
nation of small-pox, there will generally be found congestion and infiltration of the 
mucous membrane of the alimentary canal and some of the internal organs, especially 



DISEASES OF THE SKIN. 499 

eases, but in none can one be relied upon with, so much certainty, and 
accomplished by such a simple, harmless procedure, as in variola. It 
is inoculation with the small-pox lymph from the cow, or 

YACCmATION^. 

An eruption of pustules occurs in our domestic animals, and the 
pocks on the udder, in particular, have been known for a long time. 
"V^Tiether these always originate through contagion, or spontaneously, 
is not yet satisfactorily decided; their course, however, has been 
accurately observed. Canstatt reports as follows concerning it : 

A few days before the eruption the cows eat less, give less milk, 
and the udder has an increased temperature. Soon after this, small 
reddish tubercles appear, especially on the external surfaces of the 
teats, which become converted into umbilicated pustules, and between 
the fourth and seventh day these have attained to complete maturity. 
The pustules have a pearly color, at first are filled with clear lymph, 
which subsequently becomes purulent, and they are surrounded by red 
areolae. Touching the udder causes the animal marked pain. The 
pustules desiccate by the twelfth or fourteenth day, fall off, and leave 
circular cicatrices. 

It was known for more than a hundred years that those who had to 

the brain and lungs. The serous coat of the blood-vessels seems turgid and of a 
blood-red color. The pustules are found scattered over the mouth, pharynx, oesoph- 
agus, and rectum, particularly if the patient have succumbed during the suppurative 
stage. Occasionally they are seen in the larynx, trachea, and bronchi, and the urinary 
bladder. Where they have ruptured, the mucous membrane will be found covered 
•with an adventitious membrane. Each well-formed pustule, when carefully dissected, 
will be seen to consist of two compartments, the upper one being the larger. These 
compartments are both filled with pus, and communicate with each other at the 
marginal borders. This septum is a layer of false membrane, deposited in the derma 
at an early stage of the disease, which, by removing the surface-layer of the pustule, 
is brought into view, presenting a bright-red or purple color, and is highly infecting. 
But the mature pustule is multilocular, and, when a transverse section is made, pre- 
sents an appearance that has been compared to a severed orange. 

The urinary secretion in variola undergoes certain changes corresponding with the 
gradations of the disease. During the eruptive fever the quantity is lessened, its spe- 
cific gravity increased, its color deep red and turbid, and it sometimes contains traces 
of albumen. Becquerel states that, " in five cases with severe symptoms during the 
eruptive stage, the quantity of urine was diminished, amounting on an average to only 
twenty -three and a half ounces in twenty-four hours. There was no increase in the 
specific gravity, it being only 1020.6. It frequently precipitated uric acid, either 
spontaneously or by adding nitric acid, and in one case only was a trace of albumen 
discovered." During the suppurative stage " the urine retained the synochal char- 
acter so long as the symptoms continued, remaining unaltered, and, in the cases in 
which the fever persisted, till fatal termination. Sediments containing muco-pus also 
appeared in it." During the period of desquamation, " it is either normal or limpid," 



500 DISEASES OF CHILDREN. 

feed or milk such cows would become infected, and it also became a 
notorious fact that these persons remained exempt from the genuine 
small-pox. But the first accurate test and experimental confirmation of 
this fact was not instituted till the 14th of May, 1796, when Jennei\ 
for the first time, inoculated a child eight years of age with the matter 
taken from the hands of a milker. The counter-test was instituted in 
this child on the first day of July following, by inoculating it with gen- 
uine variola poison. The child remained unafi"ected. This experiment 
was subsequently repeatedly performed, and the first public vaccinat- 
ing institution was estabhshed in London as early as 1799. Since that 
time this sanitary measure has spread and become renowned through- 
out the civilized world, and there is hardly a country now where 
vaccination in the first year of life is not prescribed by law. 

Vaccination is best performed in the following manner : first of all, 
it shoiild be stated that the child from which the matter is to be taken 
must be perfectly developed, entirely free from cutaneous eruptions, 
and free from febrile diseases. If it has been vaccinated eight days 
previously, it ^vill now present several perfectly legitimate vaccine 
pustules. One of these is punctured with the vaccinating needle, 
held obliquely in such a manner that j^ure lymph only, unmixed with 

wiiile, in the putrid form, " it appears decomposed, ammoniacal, and not unfrequently 
of a dark-red color, from the presence of heematine." 

The treatment of simple variola, when uncomplicated by any other disease, is as 
thoroughly expectant as the treatment of any other exanthema. Confinement to bed, 
cooling regimen, diluents, sponging the skin with tepid water, and the occasional use 
of a saline purgative, is all that is necessary. When the secondary fever sets in, 
febrifuge salines, such as potass, citras, or liq, ammo, acetas, or the effervescing 
salines, may be given. Sleeplessness may be relieved by opium, and, when the vital 
powers begin to fail, stimulants and a generous diet are indicated, "Where the cere- 
'bral symptoms are severe, leeches, according to the age of the child, may be applied 
behind the ear, and mustard-draughts to the feet. Mineral acids are useful in cases 
which are complicated with hsemorrhages, and, if conjunctivitis exists, emollient poul- 
tices to the eyelids may greatly relieve it. If the eruption is tardy, a warm bath and 
sudorifics may hasten its appearance. During the secondary fever, small doses of 
opium will be found very serviceable, but this is contraindicated in the primary one, on 
account of the extreme excitabihty of the nervous system. In the graver forms, where 
the vital organs have been attacked, a more energetic treatment must be employed. If 
the disease has assumed an unfavorable type, from the very first, or the nervous 
symptoms are of a severe character, stimulants and tonics, with a nutritious diet, 
will have to be liberally administered. Symptoms indicative of serious internal con- 
gestion are best combated with dry cups and counter-irritation. Abstractions of blood, 
even topically, as a rule, are inadmissible in small-pox, particularly in the confluent 
variety, when the full quota of strength will be required to withstand the great drain 
upon the system from the extensive suppurating surface. Headache and delirium 
are best relieved by the application of ice to the head, or cold-water affusions repeated 
everv two or three hours, — Tr, 



DISEASES OF THE SKIN. 501 

blood, will escape. One or two minutes are always required before a 
large drop appears, for the reason tbat vaccine pustules,* as is well 
kno\vn, are not simple, but multilocular vesicles. After the needle 
has been wiped perfectly dry, it is dipped in this Ijmiph in such a 
manner that its anterior and dorsal surfaces are moistened by it. The 
arm of the child to be vaccinated is grasped below the shoulder, the 
integument on the outer sm^face of the upper third is made properly 
tense, and the point of the needle is made to pierce the skin four or 
five times. The punctures ought not to bleed, and the vaccination 
succeeds best when a minute red dot only is seen afterward. The 
punctures should be at a distance of at least six lines from each other, 
for otherwise the pustules that are subsequently to appear will coalesce. 

The summer is the most proper time of the year to vaccinate, 
because in mnter the jDustules have been observed to develop 
very slowly. The best age is between three and twelve months. Still, 
when epidemics of small-pox prevail, infants may be vaccinated a few 
days after birth. Those children about to be vaccinated must be per- 
fectly well, and free from any of the troubles of dentition (vide p. 106). 

Vaccinated children require no special treatment. They may be 
washed and bathed afterward as well as before, and, from the fourth to 
the tenth day, the arm may be wrapped up in a fine piece of hnen, 
merely to prevent friction. The erythema surrounding the pustules 
is thereby also kept within proper bounds. 

The transmission of the cachexise from one child to another by 
vaccination has only been proven in regard to syphilis. Scrofula and 
rachitis cannot be transmitted by vaccination ; but, since the most cor- 
rect views do not always prevail among the public in regard to this 
point, and in order to avoid all future reproach, it is best to take the 
matter from healthy children only, and w^ho are entirely free from 
cutaneous diseases. 

It is well to take the precaution to have vaccine lymph constantly 
on hand, in order that, in case an epidemic breaks out, it should not 
first have to be looked for or ordered. It is collected without any 
difficulty or trouble in the following manner : one or several well-de- 
veloped eight-day vaccine vesicles of a healthy child are punctured 
several times, and a few^ minutes allowed for the escape of the drop. 
It will then have become tolerably large, when an ordinary glass capil- 
lary tube held slightly oblique with its end in the drop of lymph, ma}^ 
be charged. The capillary tube must be held parallel with the arm for 
this reason, that, in case the child should stir or become restless, it will 
not be injured by it. I remember once to have had a child imder 

* European authors generally use the word pustule for the vesicular stage of vac- 
cinia. — Tr. 



502 DISEASES OF CHILDREN. 

treatment, in whom the glass tube was broken in consequence of the 
clumsy manner in which it was applied, the glass fragments were forced 
into the pustules, and a mahgnant erysipelas of the whole arm was the 
result. The little tube, according to the laws of capillary attraction, 
soon becomes filled with lymph, and may be withdrawn and cut off with 
the scissors, leaving about one-eighth or one-fourth of an inch unfilled 
at both ends, which are then closed with sealing-wax. In this manner 
vaccine lymph may be preserved in a fluid form for years. 

When the lymph thus preserved is about to be used for vaccination, 
the two closed ends should be cut off with the scissors, the capillary tube 
is thrust into another somewhat larger glass tube, both are held be- 
tween the thumb and index-finger, and the vaccine matter is blown 
directly upon the lancet. The vaccination is thereafter carried on as 
in the ordinary way, from arm to arm. 

The vaccine pustule develops in the following manner : the small 
punctures may be seen for a few hours as minute dots. If no bleeding 
at all has taken place, all traces of the puncture will disappear, but, if 
that was the case, a few dark-brown spots will be visible for some 
time. On the third day after the vaccination, the vaccinated spot be- 
comes markedly red, and a small, round, hard tubercle arises, upon the 
apex of which a pearl-like vesicle becomes developed by the fifth day. 
This vesicle daily grows in breadth, becomes distinctly umbihcated, 
like a variola pustule, and by the eighth day has reached the acme of 
florescence, when it will be seen as a bluish-red translucent pustule, 
surrounded by a red areola. 

The pustules are constructed in compartments ; their contents be- 
gin to turn turbid on the ninth day, the red areola enlarges more and 
more, the induration increases, the glands in the axilla become sensi- 
tive, and general symptoms supervene. The children become very 
restless, do not sleep at night, have a hot skin, great thirst, and are 
very much disposed to acute diseases, especially pneumonia and intes- 
tinal catarrhs. These general phenomena disappear in two or three 
days. From the eleventh day on, the red areola fades, and the opaque 
pustule acuminates and loses its central depression. When properly 
protected, it will not burst, but dry up into a brown crust, which falls off 
in two or three weeks, and leaves behind a white, depressed, somewhat 
irregular cicatrix, which, if scratched, will suppurate for a few hours, 
and then likewise dry up into a large crust with irregular contours. 

The course of vaccination is not always so regular and simple as 
it has been sketched above. The secondary fever sometimes becomes 
so intense that life seems to be in danger. The children are attacked 
by severe convulsions, become collapsed, look very pale, or vomit, con- 
tinuously, at first white, then bilious gastric mucus. No instance, how- 



DISEASES OF THE SKIN. 503 

ever, has been heard of where the secondary fever brought about a fatal 
termination ; and, when children with vaccine pustules die, some other 
remote cause of death will be found on csireiui 2:>ost-?nortem examination. 

In children with a fine, irritable skin, other parts of the integu- 
ment become affected ; a nettle-rash or a varicella-like eruption of vesi- 
cles occurs on the whole or some part of the body. Scrofulous chil- 
dren are attacked by an extensive pustular eruption, in which the 
vaccinated arm especially participates, and then the vaccine pustules 
will not heal at all, but degenerate into scrofulous ulcers. 

Erysipelatous inflammation of the arm is one of the worst comph- 
catious which, through rough treatment of the pustules, particularly 
in cachectic persons, may develop between the ninth and twelfth day. 
The erysipelas spreads over the entire arm, even over a part of the 
trunk, the fever is intense, recovery progresses but very slowly, and 
the pustules ulcerate. 

A too rapid and a too slow formation of pustules may be mentioned 
under the head of anomalies of the local course. If the vaccine lymph 
was poor, obtained from an imperfectly-developed pustule, small vesi- 
cles will form as early as the second or third day, will be but (little 
umbilicated, barely attain to the size of a lentil, and dry up in six or 
eight days. On the other hand, as a rare anomaly, instances are re- 
lated in which the eruption has been materially retarded, and the pe- 
riod of incubation was eight to ten days. I cannot remember to have 
observed a single instance of this kind in the many hundreds of cases 
that I have had the opportunity of vaccinating. 

As a real sequela of a vaccination which has been performed with 
all due caution, the sudden breaking out of scrofulous affections only 
need be mentioned. This occurs in children the progeny of tubercu- 
lous parents, and they are often attacked with remarkable rapidity 
and vehemence. 

The question. How long a time does vaccination serve as a protec- 
tion against variola ? has been considerably ventilated, and the inves- 
tigations that have been instituted for the purpose of solving this 
question have finally led to the general estabhshment of a revaccina- 
tion at the time of puberty. Whether it is assumed that vaccination 
protects for life, or only for ten or twenty years, it is, at least, certain 
that children who have had proper vaccine pustules are totally pro- 
tected against genuine variola. Hence vaccination is to be looked 
upon as a great blessing to humanity, in which light also the Parlia- 
ment of England regarded it, and, in gratitude to its discoverer, voted 
him a national gift of thirty thousand pounds sterling. 

If the genuine or modified small-pox breaks out in a family in 
wliich one child is not yet vaccinated, this child should be vaccinated 



504 DISEASES OF CHILDREX. 

as quickly as possible, so as to mitigate the course of tlie exanthema, 
which usually breaks out notwithstanding. The vaccine and small- 
pox pustules then run an undisturbed course together. Still, it has 
been observed that, when vaccinia anticipates the general exanthema, 
the latter assumes a less dangerous character. 

The treatment of small-pox is to be conducted in as expectant a 
manner as scarlet fever and measles, being directed to the symptoms 
as they occur. The ventilation of the room should be carefully 
looked after, the temperature should be 58° F., and all weakening 
measures, such as abstraction of blood, calomel, and cathartics, must 
be absolutely avoided. When intestinal catarrh is present, as is usu- 
ally the case in children under one year of age, it need not be inter- 
fered with so long as it is moderate, as the cerebral symptoms are 
thereby visibly mitigated ; but, so soon as it threatens to become pro- 
fuse, an attempt is to be made to control it by small doses of opium, 
one drop of the tincture every three or four hours. 

With the hreaking out of the pocks, the indication is to prevent the 
development of the pustules in the face, and with it the formation of 
cicatrices, which so frightfully disfigure the patient. All the reme- 
dies recommended for that purpose are sadly deficient in many re- 
spects, and perceptible cicatrices result, notwithstanding all manner 
of treatment. An early cauterization of the pustules, which, accord- 
ing to JBretonneau, is performed by dipping a pointed gold needle in 
a concentrated solution of nitrate of silver, and then puncturing with 
it every young pustule, is the surest remedy. 

If the pustules are thus cauterized on the second day of the erup- 
tion, they will be arrested in their development ; and the integument 
in a few days becomes elevated by a thin crust, and, after it has fallen 
ofi", no deforming cicatrices will be perceptible. 

But this cauterization is painful, and, in confluent small-pox, re- 
quires much time, owing to which this treatment has been limited to 
the eyes, eyehds, and nose, while the other parts of the face, the fore- 
head, cheeks, and chin, are covered -with mercurial plaster. It must 
be changed every other day, and should be discarded altogether if the 
pustules have become developed notwithstanding. One portion of 
the pustules, no doubt, is arrested and destroyed by this treatment ; 
another does not attain to a proper, extensive development, and very 
few only leave permanent, disfiguring cicatrices. 

Lotions of corrosive sublimate, chlorine-water, and painting the 
face with iodine, have also been recommended.* The general man- 

* Prof. J. Hughes Bennett recommends the following mixture : carbonate of zinc, 
three parts ; oxide of zinc, one part, rubbed in a mortar with olive-oil to a proper 
consistence. — A solution of gutta-percha in chloroform is equally as efficacious as the 



DISEASES OF THE SKIN. 505 

agement after the eruption is limited to an antiphlogistic diet, to 
keeping the bowels open, and, when the restlessness is very great, to 
the administration of small doses of opium. 

The utmost attention will be required during the periods of suppu- 
ration and desiccation, to prevent the patients from scratching them- 
selves and prematm-ely tearing off the crusts. Linen mittens, secured 
at the wrists, will be found to be of great benefit. Starch, powder, or 
a Hniment of lime-water and olive-oil, is very ef&cacious in assuaging 
the itching of the skin. The patients should not leave the room till the 
crusts have fallen off, and the new cicatrized sldn begins to turn white. 

If the fever has assumed a torpid, septic character, nervines and 
tonics should be plentifully administered, such as have already been 
described in detail in the therapeutics of scarlet fever. 

(5.) Modified Small-pox, Varioloid and Vakicella, Chickex- 
pox. — Both physicians and the public had been familiar with a mild 
form of cliildren's disease, known by the names of varicella and 
chicken-pox, long before vaccination was discovered. But there is a 
long list of gradations between this lowest step of development of 
small-230x and the most perfect form of confluent variola, all of which 
have been comprised under the name of varioloid, or modified small- 
pox. To regard them as exanthemata capable of existing by themselves, 
without any direct connection with genuine small-pox, is not very 
proper, for the simple reason that it has often happened that unvacci- 
nated patients, with mild varicella, were attacked by the severest 
forms of small-pox ; and, conversely, that vaccinated persons, through 
contact with patients having genuine small-pox, acquired only vari- 
cella. 

Nevertheless, it is advisable, in order more easily to comprehend 
these affections, to retain the old denominations. Both of these cer- 
tainly not very distinctly-defined forms of disease, varioloid and vari- 
cella, will therefore here be separately considered. 

Symptoms of Varioloid. — The same stages may be observed in 
varioloid as in variola, but they are all of shorter duration, and less 
sharply defined. The entire duration of variola, from the invasion of the 
prodromata until the desiccation of the pustules, embraces a period of 
from sixteen to eighteen days, that of varioloid from seven to eleven daj's. 

The jjrodromata are the same as in variola, but usually do not last 
three full days, twenty-four to thirty-six hours at the most, and are 
less intense in general. The specific smell of small-pox is totally ab- 
sent in varioloid ; on the other hand, a dark-red, large-spotted erythe- 
ma of the integument, which has been described by the name of 

preceding remedy. And, of late, carbolic acid has also been recommended for the 
same purpose. — Tr. 



506 DISEASES OF CHILDKEN. 

"rasb," supervenes, a sign not usually seen in variola. This erythema 
is not to be regarded as the commencement of the pustular eruption, 
for the pustules that subsequently develop may appear upon the parts 
of the body which the rash has not invaded. 

The exanthema breaks out more rapidly and less uniformly. The 
eruption does not begin on the face alone, nor does it descend gradu- 
ally upon the trunk and the lower extremities, but appears almost 
simultaneously upon the whole body. Whereas, in variola, all the 
pustules on one part of the body are at an equal stage of develop- 
ment, and no new accessions are noticeable ; while, on the contrary, in 
%'arioloid tubercles, vesicles and large pustules are usually found along- 
side of each other, and the number of the pustules increases for sev- 
eral days. While it is true that solitary pustules, which, in regard to 
form and structure, differ in no way from those of genuine small-pox, 
occur in varioloid, the majority of them, however, do not become um- 
bilicated pustules, but remain hyaline vesicles of the size of hemp- 
seed, and desiccate into correspondingly thin scabs. 

The general symptoms, which were very slight from the com- 
mencement, either disappear entirely with the eruption of the exan- 
thema, or are, at least, reduced to a minimum. No real secondary fever 
occurs in this disease, and the patients, in most instances, feel so well 
that they can hardly be kept in bed. Even the most developed pus- 
tules begin to dry up by the fifth or sixth day at the latest, and occa- 
sionally a few sohtary followers are observed in the midst of the dry- 
ing ones, but they only become vesicles, and usually, as such, soon 
perish. The suppuration of the pustules never becomes so intense as 
to produce an erysipelatous redness around them, and but few of them 
ever burst. They usually dry up quickly, the crusts fall off in a few 
days, and leave behind them slightly-red, barely-depressed cicatrices. 
The pustules on the mucous membrane of the mouth and pharynx 
heal in an equally short time. 

Sequelce are rare in varioloid, and attended by little danger in pre- 
\dously healthy children. Occasionally an obstinate furunculosis, or a 
profusely suppurating impetigo, follows. The latter is generally at- 
tended by swelling of the adjacent lymphatic glands. In most scrofu- 
lous children the various cachectic affections make very rapid progress. 

The ])'^^ognosis is more favorable than in variola, for, of children 
under one year, only eight to ten per cent., and of older ones from 
five to six per cent., perish. 

The danger especially to be apprehended is from a participation of 
the larynx, through Avhich croup-symptoms and sudden oedema of the 
glottis are occasioned. Convulsions which have a tendency to a rapid 
fatal termination, complication with pneumonia or meningitis, and 



DISEASES OF THE SKIN. 507 

finally a septic character of the fever that exceptionally becomes de- 
veloped, are among the recognized sequelae. 

Treatment. — Vaccination oifers no protection against varioloid, as 
it only modifies the contagion of genuine small-pox to such an extent 
that, when communicated to a vaccinated child, it at most produces 
varioloid. But, since it has often been observed that varioloid runs a 
milder course in a vaccinated child than in one that is not vaccinated, 
vaccination must therefore, in this respect, also be looked upon as a 
beneficial projDhylactic. 

The treatment of the disease that has already broken out is purely 
expectant. Every tiling that has been said with respect to variola is 
apphcable to varioloid. No cauterization of the pustules on the face 
is necessary in this case, for the pustules penetrate less deeply into the 
cutis, and only leave superficial pittings. Disfiguring cicatrices of the 
face, as a rule, may be readily prevented by the aid of mercurial plaster. 

In the early stage of the disease it is best to give some diluted 
mineral acid ; if diarrhoea be present, mucilaginous remedies. In laryn- 
geal croup, the greatest benefit is derived from intense cauterizations 
of the pharynx, larynx and epiglottis, mth a concentrated solution of 
nitrate of silver ( 3 ss to water 3 j). These cauterizations are easily 
performed ; but, in order to be convinced that the contents of the cau- 
terizing sponge find their way into the larynx, the index-finger of the 
left-hand should first be thrust quickly far into the mouth of the child, 
the epiglottis raised up, and the sponge then rapidly pressed into the 
glottis. The head of the child should be held firmly and steadily by 
an assistant. This procedure always requires a certain amount of 
dexterity and practice. In children who have teeth, it is advisable to 
protect the last joint of the index-finger with some lint, before it is 
introduced into the mouth, for they are very apt to bite it severely. 

In small children, the immoderate amount of scratching during 
the desiccating stage may be prevented by the aid of linen mittens ; 
older children, naturally, are much ofi'ended and annoyed by this pro- 
cedure. In the latter, the nails, at least, should be cut off as short 
as possible. 

Convalescence usually progresses rapidly, and a special tonic after- 
treatment will but very seldom be required. 

Symptoms of Varicella. — Varicella, also called false, chicken, water, 
swine, or stone pox, is the least dangerous, the most insignificant of 
all exanthematous affections, and the majority of cases, especially 
during the prevalence of an epidemic, do not come at all under medi- 
cal supervision. 

Hardly any precursory signs are observed in large and other- 
wise healthy children. Occasionally slight gastric symptoms, vomit- 



508 DISEASES OF CHILDREN. 

ing, loss of appetite, stomacli-aclie, mild febrile phenomena, and 
urinary difficulties, precede the eruption of the exanthema for one, 
at the most two days. 

The exanthema, without any particular aggravation of these pro- 
dromatory symptoms, now breaks out simultaneously upon different 
parts of the body without any a^Dparent order. In from six to twelve 
hours small red spots grow into vesicles of the size of lentils or peas, 
which, regarded by themselves, cannot be distinguished from small 
blisters produced by a burn. Most of them are circular, or slightly 
oval and unilocular, and when punctured the entire contents escape 
at once. They are not at all, or but slightly, umbilicated. The ma- 
jority of these vesicles are found upon the back and breast, a few 
upon the extremities, and the least upon the face, one or two pus- 
tules only appearing on the forehead. 

Usually it is not completed by one eruption, but a second crop of 
vesicles appears on the next day, and then we have fresh and totally- 
dried varicella vesicles alongside of each other. Although most of 
the vesicles are not larger than a lentil, several pustules are found in 
all varicella patients, upon the forehead or back, which are slightly 
umbihcated, and resemble the genuine variola pustule. 

The course of most of the vesicles is very rapid. Their contents 
become turbid as early as the second or third day, and dry up on the 
fourth ; flat, bloody crusts then form, which fall off in a few days, and 
leave no pitting, but a red spot. The narrow red areolse which formed 
at the time the vesicles became opaque, disappear as soon as the crusts 
have desiccated. 

The red spot, which for several weeks indicates the former site of 
the crust, is not to be seen after this time. 

Unless accessions of vesicles particularly protract the course, the 
whole disease, with the exception of the red spots just mentioned, 
marking the site of the pustules, is entirely completed in from eight 
to ten days. These red spots will remain for some time thereafter. 
No sequelse are observed in this affection, but, in scrofulous children, 
chronic suppurating eruptions sometimes develop directly from the 
vesicles and resist for a long time the desiccatino^ treatment. Vari- 
cella regularly terminates in rapid recovery. 

The variations of ordinary chicken-pox described in medical litera- 
ture are : varicellse lenticulares, where none of the vesicles are larger 
than lentils, and not umbihcated; and varicellas coniformes, or acu- 
minata, the so-called horn-pox, where hard tubercles form at first upon 
the skin, on which small acuminated vesicles originate the next day. 
The vesicle dries very quickly, and its indurated base shrinks by re- 
peated desquamations. 



DISEASES OF THE SKIN. 509 

If we are to recapitulate the essential differences between varioloid 
and varicella, we will find that varicella, in contradistinction to the 
former, has but a short or no precursory stage, that the exanthema 
appears in a perfectly orderless manner, and is followed by many 
accessions, the face being almost wholly spared ; that it dries up in 
two or three days and leaves no pitting. No danger to life, nor any 
permanent injury, is to be apprehended from varicella. Vaccination 
and genuine small-pox do not serve as protection against varicella. 

Treatment of Varicella. — If an expectant treatment has been pro- 
nounced sufficient for varioloid, it is of course still more so for vari- 
cella. When the children are free from fever, as is usually the case, 
it is a difficult task to put them in bed. Nor is it absolutely necessary 
to keep varicella patients in bed, for no bad effects are usually seen, 
even when they are allowed the utmost freedom, and expose them- 
selves to great changes of the temperature. 

Where febrile prodromatory symptoms are present, some mild 
laxative, such as tamarinds or neutral salts, may be prescribed. The 
pustules should be pencilled over with a little oil or cocoa-butter ; the 
patients are, for a few days, put upon a bland vegetable diet, and 
kept in a room of uniform temperature. The disturbed activity of the 
skin is remedied by three or four lukewarm-water baths after the 
crusts have fallen off. 

(6.) Eetthema Neo:s^atoeijm. — Besides the physiological red 
discoloration of the skin, with which all normal children come into the 
world, and which, after a few days, becomes yellowish red, and finally 
bright red, an erythema papulosum also very frequently occurs in new- 
born children. 

Symptoms. — The erythema is usually most strongly developed 
upon the breast and back, and consists of small, dark-red pimples rest- 
ing upon an equally red base. The cutis is but slightly infiltrated ; 
itching of the skin seems to be present, for all the patients are 
uneasy so long as the exanthema is visible. On pressure by the finger 
the redness quickly disappears, but returns again in an increased de- 
gree as soon as it is removed. The erythema fades in a few days, 
and the darkest spots desquamate in very thin scales. 

There is nothing typical whatever to be observed in its whole 
course, and the entire process is sometimes completed in two, some- 
times again in fourteen days. The child may also be attacked by it 
more than once. Hardly any general symptoms are occasioned by it, 
the children have no fever, the mucous membranes do not participate 
in this affection, and the appetite is not disturbed, which fiict alone 
sufficiently distinguishes this erythema from scarlatina and rubeola. 
The exanthema itself, certainly, has the greatest resemblance to scarla- 



510 DISEASES OF CHILDREN. 

tina, and, but for the accompanying symptoms, might be mistaken for 
this exanthema. It is a fact worth remembering, that new-born chil- 
dren are but little predisposed to take scarlatina. 

Etiology. — The causes of this erythema, most probably, are external, 
from the circumstance that these children are attacked by it in the first 
few days of hfe, and from its repeated occurrence in one individual. In- 
deed, the delicate skin does not tolerate, from the very first, the irrita- 
tion of the garments and baths, and is thereby excited into a high de- 
gree of hypersemia, which constitutes erythema papulosum. 

Treatment. — Since erythema expires spontaneously in a short 
time, its treatment may be simply expectant. The skin should not be 
rubbed nor irritated so long as the erythema exists, especially after the 
baths, which need not be omitted even for one day. The patients, 
however, should be simply wrapped up in dry cloths, and all rubbing 
avoided. JMild infrictions of ol. coccos, or some other pure oil, seem 
to be soothing to these children. During this period their underclothes 
and diapers should be as fine and soft as possible. 

(7.) Erysipelas. — In children of from five to fifteen years, ery- 
sipelas, which differs in no respect from that of the adult, occurs, 
and it consequently deserves no further consideration here. But ery- 
sipelas of the new-born child and nurshng presents such important 
modifications, especially symptomatically and prognosticaUy, that it 
seems to caU for an especial description. 

This kind of erysipelas is distinguished by a great and constant 
disposition to migrate, not limiting itself to any small or large portion 
of the body, but creeping over the entire surface of the skin. Adjacent 
parts are constantly attacked, while those previously affected fade 
gradually, and the disease is not arrested until the whole surface of the 
body has been implicated. In exceptional cases the pernicious pro- 
cess is not content with even this, but begins anew, at some place, and 
again wanders over a greater or less portion of the body. 

The local symptoms do not differ from ordinary erysipelas — red- 
ness, swelling, warmth, and pain on pressure. The exanthema remains 
in its florescence from one to tlu-ee days, and fades remarkably quickly 
as soon as it has attacked new parts. 

The whole course, in the rare cases of recovery, lasts from four to 
five weeks. New-born children invariably succumb to it in a few days, 
and even infants several months old only recover very exceptionally. 

Etiology. — In new-born children erysipelas almost always starts 
from the navel, and is especially often observed during an epidemic 
of puerperal fever, when, in fact, the navel never cicatrizes normally. 
In older children all possible injuries of the skin may supply a cause for 
this disease. Erysipelas most frequently follows vaccine and impetigo 



DISEASES OF THE SKIN. 511 

pustules, but may also take its rise from a simple abrasion (intertrigo) 
of a cutaneous fold. But the great frequency with which these cutane- 
ous excoriations occur on the one hand, and the rarity of erysipelas on 
the other, render a positive disposition to erysipelas necessary to ac- 
count for its appearance in these cases. 

Treatment. — AU attempts to localize erysipelas, to prevent its 
spreading, have hitherto proved futile. Even ferrum can dens (the ac- 
tual cautery) has been tried, but has proved ineffectual to check the 
progress of the inflammation. 

The internal treatment at any rate must be by tonics and stimu- 
lants. The English physicians claim to have derived benefit from tr. 
ferri muriatici oxid. in two-drop doses every hour. In the few chil- 
dren whom I have seen recover from erysipelas, I administered from 
two to three grains of quinine daily for several days, and a teaspoon- 
ful of Bordeaux brandy every hour for several weeks. Locally ol. 
coccos was only apphed. 

(8.) I^sTEETKiGO (Chafixg). — By intertrigo is understood a destruc- 
tion of the epidermis covering the opposing surfaces of a cutaneous 
fold, resulting from the rubbing of the two surfaces against each 
other. It is seen most frequently between the nates, in the groins, 
the armpits, and on the neck. Corpulent children, moreover, may be- 
come chafed on all the cutaneous folds of the body, though otherwise 
possessing excellent health, and having the best attention ; in lean chil- 
dren this only happens when the diapers, soaked in diarrhoeal excre- 
tions and urine, are allowed to remain in contact with the skin for 
some time. 

Redness and moisture of the affected integumentary folds is the 
first degree of intertrigo. The epidermis next softens, and may be 
wiped off as a white mucus, when the cutis will be seen totally exposed, 
dark-red in color, and painful to the touch. The secretion, that now 
becomes considerable, may increase in amount sufficiently to form 
crusts. With cleanliness and proper treatment, the loss of epidermis 
is soon repaired ; but where the subjects are cachectic or atrophic, and 
if the primary cause, the diarrhoea, continues, the erosions will assume 
an ulcerative form, may become coated with diphtheritic membranes, 
and in the worst cases even gangrenous. 

The ordinary intertrigo of corpulent children, under an appropriate 
treatment, disappears in two or three days, that occurring in atrophic 
children never heals so long as the diarrhoea lasts. 

Treatment. — As a prophylactic in corpulent children, semen lyco- 
podii is very advantageously dusted in the cutaneous folds ; it pre- 
vents the rubbing and contact of the surfaces, and by its feeble hygro- 
scopic properties preserves them dry for some time. Usually, it is 



512 DISEASES OF CHILDREN". 

also employed by the laity as a remedy in cases where the epidermis 
has already been lost, but here it is altogether out of place. The 
secreted exudation combines with the lycopodium, forms hard, large 
crusts, and considerably increases the inflammation of the skin. 
T\Tiere this injudicious measiu-e has been employed, the crusts are fii-st 
to be soaked off with oil, and carefully removed. The existing excoria- 
tions are best treated with lead or zinc ointment, and, among the 
poor, ordinary tallow may be substituted for these remedies. Tepid 
baths are the best preventive against chafing. 

(9.) FuEiTXCULOSis. — Children of various ages frequently sufi'er 
from solitary furuncles or boils, which, corresponding with the more 
rapid metamorphosis of the tissues generally, comparatively quickly 
cast off their core and soon heal up. But, in children the progeny of 
tuberculous parents, the case is totally different. 

In the latter, large numbers of furuncles occasionally occur on the 
occiput and over the entire head, come on one after the other, break, 
and cause the child great suffering for a long time. Usually no firm 
core is expelled, as in the simple phlegmons, the contents consisting 
only of thick, yellowish, or bloody pus, which often becomes aggluti- 
nated with the surrounding hairs into thick flat crusts. 

Coincident swelhng of the glands of the nape of the neck occurs ; 
they are very painful to the touch, and, in fact, now and then suppu- 
rate. 

These furimcles may become so numerous that the whole occiput 
is finally covered with a mass of confluent crusts, under which new 
ones constantly appear, elevate the old crusts, and, by the discharge 
of their contents, assist in thickening it. In this manner the extreme- 
ly painful process is protracted for many weeks. Young children 
hardly sleep at all, but older ones, when the nurse takes them upon 
her arms, wliere they can then lay their face upon her shoulder, are 
able to sleep. Finally, the crusts dry up, and no accessions follow. 
The scabs become loose and may be removed, together with the hair, 
or what there is left of it. The marks of the phlegmon may be recog- 
nized for some time after by the bluish-red, glistening cicatrices. The 
consecutive swelling of the cervical glands also disappears. The nutri- 
tion and development of the children, from the constant sleeplessness, 
suffer in an extreme degree ; but, if the digestive organs are not at- 
tacked by cataiTh, they will rapidly improve after the furunculosis has 
been cured. 

In perfectly healthy children this disease is scarcely ever observed ; 
but ordinarily it is the harbinger of a long list of scrofulous affections. 

Treatment. — This affection cannot be cut short. The only thing 
the physician can do is to attempt to remove the constant restlessness 



DISEASES OF THE SKIN. 513 

and sleeplessness, by wliicli a great service is rendered to the patients 
and their relatives. This is very easily done by one or two drojDS of 
laudanum, by wliich a few hours of refreshing sleep are induced, even 
in the most restless children. No bad effects are ever seen from this 
moderate use of opium. 

Locally, the crusts are best treated with some oleaginous sub- 
stance. Simple cerate, or some mild ointment, is applied daily until 
the crusts soften and fall of. By these measures, the painful pulling 
of the agglutinated hairs is avoided. No relief is obtained from pre- 
matiu-ely opening the boils, and it is best, therefore, to wait until they 
are sufficiently large, and the apices have become yellowish, when 
they may be punctured w^th a needle. By this means the painful 
tension and several hours of pain may be avoided. 

(10.) Scabies — Itch, — Since, in the composition of this chapter, 
a knowledge of the diseases of the skin in general is presupposed, I 
may appropriately omit a zoological description of the itch animalcule, 
and immediately proceed to speak of the morbid alterations of the 
skin produced by it in small children. The best description and repre- 
sentation of the acarus scabiei are to be found in Sitnons's Diseases of 
the Skin, and Kuchenmeister' s Parasites. 

Symptoms. — The acarus scabiei penetrates, with especial preference 
and remarkable rapidity, the delicate epidermis of the nursling, and, a 
few days after the infection has taken place, the consecutive exan- 
thema begins to appear. In young children this varies according to 
their age. Very young infants, a few weeks old only, have it in a less 
degree, because they are still unable to scratch themselves so severely, 
while those a few months old become universally covered with it. 

Generally, the exanthema is most developed upon the hands, but- 
tocks, and abdomen, and at first presents the following form ; A rose- 
colored papule originates upon various parts of the body, and upon 
their apices small transparent vesicles become developed, accompanied 
by intense itching. When these vesicles remain uninjured, their con- 
tents in a few days will become opaque and purulent, and thus form 
pustules which burst spontaneously, and leave behind them a yellow 
circular crust. But, if the vesicles are prematurely scratched open, as 
is usually the case, then these irritated spots will bleed a little, and 
the small crusts that then form are of a black color. 

The more the children scratch, the more extensive will become the 
exanthema. By the coalescence of single pustules, large ulcers often 
form, especially on the lower extremities and on the buttocks. These 
ulcers resist the treatment for a long time, and, in chronic cases, the 
whole skin, even those parts of it that are free from pustules, assumes 
a dry, scabby character. 
33 



514. DISEASES OF CHILDEEN. 

The state of the general system of small children is much affected, 
in consequence of the incessant itching and sleepless nights, and 
they become visibly emaciated if the scabies is not properly treated, 
which is, unfortunately, often the case even at this day. 

As regards age, new-born children are the only ones exempt from 
it, for the reason that the animalcule requires several days to penetrate 
the epidermis, and to produce the exanthema. Not until this has 
taken place do we become aware of the course of the animalcule, for, 
previous to that, there is, in most instances, no cause for examining 
the integument with great attention. Infants a few weeks old are 
very susceptible to the itch, and generally acquire it if any child 
has introduced it into the house. 

Scabies is more difficult to diagnosticate in children than in adults, 
because the animalcule has not, as in the latter, a preference for the 
hands, but burrows its passage (or cuniculus) at any point in the body. 
As only a single one is generally found at a time, it is often necessary 
to search for a long time before a characteristic cuniculus can be dis- 
covered. The discovery of these cuniculi is rendered still more difficult 
by their remaining perfectly white, and differing but slightly from the 
normal skin, while those on the hands of adults soon become dirty 
blackish in consequence of the different location, and cannot be made 
white by simple washing, the dirt that has found its way beneath its 
epidermis remaining entirely unaffected by the water. In young chil- 
dren these tracts are most frequently found upon the skin of the ab- 
domen and buttocks, also on the face, a condition which is never ob- 
served in adults. The attendant exanthema is always more extensive 
and severe in the former than in the latter. 

Older children, with a fine, delicate skin, sometimes have exces- 
sively large pustules, which may reach to the size of a split pea, or 
larger. When these are punctured, a large drop of pus escajDCS, and, 
generally, the pustules fill again several times if their contents are 
evacuated by repeated punctures. Most of them leave a dark-colored 
cicatrix, which is visible for a long time. This large pustular eruption 
has also been called fat scabies (fette Kratze). 

The course of scabies in children is always very tedious, and may 
be prolonged for months if proper treatment be not adopted. In ad- 
dition to that, the pustules and excoriations constantly become larger, 
and more numerous, the restlessness still greater, and the emaciation 
makes alarming progress. Finally, when almost the entire skin is 
covered with thick scabs, a spontaneous improvement seems to ensue 
even vsithout any treatment. 

Therapeutics. — The treatment of scabies in children is essentially 
different from that proper in the adult, and varies according as to 



DISEASES OF THE SKIN. 515 

whether the consecutive eruption consists only of papules, or also of 
pustules and ulcers. In infants who are still unable to scratch them- 
selves, it is usually only papulous, and, in such cases, the rapid-cure 
may very advantageously be employed. 

The whole body of the child, with the exception of the face, is 
rubbed over with green soft soap, and, half an hour after that, the 
child is placed in a warm bath, in which the soap is soon dissolved. 
After it has been carefully wiped dry, the old Helmeric ointment, 
consisting of one part of carbonate of potassa, two parts of sulphur, 
and eight of fat, is likewise smeared over the entire body, and, if pos- 
sible, should be allowed to remain upon the skin for twenty-four hours. 
But, if the latter becomes more severely inflamed, and the child very 
restless, the ointment should be removed before the expiration of that 
time by a second bath. It is hardly necessary to mention that all the 
garments and bedclothes must be changed, and thoroughly purified 
with lye. Sometimes the scabies disappears completely with the first 
infriction ; in most instances, however, this procedure will have to be 
rej^eated two or three times. This is always advisable as a precau- 
tionary measure, and may be the more readily executed, as the pa- 
tients are but little annoyed by it. 

The circumstance is entirely difi'erent when the skin is very much 
irritated by scratching, and extensive pustular or ulcerating sores 
have formed. Here the green soap produces the most excruciating 
pains when apphed to the denuded or ulcerated cutis, and oedema 
and erysipelatous inflammation on some parts of the body may be the 
result. This remedy consequently cannot then be employed. Also 
the Helmeric ointment, on account of its containing carbonate of po- 
tassa, may have to be omitted, for the sldn may be too severely irri- 
tated by it. In such children we have to content ourselves with an 
ointment, consisting of one part of f. sulphur, and four parts lard, 
rubbed in daily after each bath, and change of the garments daily. 
It will be found that, even by this mild treatment, the itching of the 
skin will be subdued, the pustules heal, and no accession occur. 

Particularly high temperatures, as is still prescribed for scabies 
wards in some hospitals, conduce but little to a rapid recovery, and 
have the great disadvantage that the patients thereby become de- 
bilitated and disposed to contract colds. 

In the treatment with the simple sulphur ointment, I allow the 
children, during the pleasant seasons of the year, to be out in the free 
air the whole day. 

That no favorable result will be attained in families, where several 
members sufi'er from scabies, unless all of them are simultaneously 
subjected to the treatment, is of itself understood. In the lower 



516 DISEASES OF CHILDREN. 

classes of people, where a sufficient change of linen cannot be com- 
manded, and the procuring of the baths is too expensive, the chances 
of a speedy recovery are very small, and the little patients will not 
get better until the older members have undergone a thorough treat- 
ment in some hospital. 

(11.) CoxGExiTAL N^vi — Mother's Marks. — As ngevus vas- 
culosus, varix, telangectasis, have already been treated of in connec- 
tion with the diseases of the vessels (page 242), it only remains for 
us to describe here the congenital pigmentary nsevi, moles, and con- 
genital adipose tumors. 

By pigmentary nsevi, stigmata, spili, spots on the skin are un- 
derstood, which are round or irregular in form, yellow, brown, black, 
or gray in color, and vary in size from a pea up to the palm of the 
hand, and, in some instances, cover even a large part of the body, the 
whole back, or an entire extremity. The alteration of color is due to 
a deposit of pigment in the Malpighian net-work. On these places the 
skin is sometimes hypertrophied and uneven, so that the mole projects 
somewhat above the sound skin, and occasionally is profusely studded 
with hairs, by wliich it is made to resemble the brown fur of an ani- 
mal. The pigmentation is not always distributed alike over the 
whole nsevus ; sometimes the centre, sometimes again the periphery 
is brighter. These pigmentary moles never become enlarged, except 
in proportion to the growth of the body in general, and occasionally 
they remain exactly of the same size as at first. 

By warts are understood higher prominences of the skin, pro- 
duced by an elongation of the papillge, and the formation of new 
tissues ; these are usually of a brown color. Those warts that so fre- 
quently originate later in older children differ essentially from these 
under consideration. The former consist of a number of perpendicu- 
lar prominences of the elongated joapillse of the skin, which are cov- 
ered by an indurated layer of epidermis. They are not pigmented, 
develop themselves on the difi'erent parts of the hands and face, and 
after several months disappear, mthout leaving any traces behind, 
and for this reason have become such desirable objects of attention 
for the so-called sympathy-cure, stupidity, and imposition. The con- 
genital warts, first described, never disappear spontaneously. 

By ncevi lipomatodes^ adipose tumors, we understand roundish 
or cylindrical fatty growths, covered with normal skm, most of which 
are pediculated, but sometimes seated upon a broad base. Strictly 
speaking, they do not belong to the diseases of the cutis, for the skin 
is entirely unaffected, but they are due to an abnormal extuberation 
of the subcutaneous adipose tissue. These usually enlarge in propor- 
tion to the growth of the body, but in some cases also faster. 



DISEASES OF THE SKIN. 51Y 

Therapeutics. — In regard to the total or partial extirpation of 
these various moles, and the cautions that are to be taken into con- 
sideration in the operation, according to their situation, we refer the 
student to the standard works on surgery. In small nasvi, surgical 
procedures may frequently be avoided by performing vaccination upon 
them. The punctures, w^ith the vaccinating needle in these cases, 
must be made so close to each other that the pustules resulting there- 
from will coalesce. 

By the seventh or eighth day the whole- naevus rises up as a high, 
painful pustule, which suppurates for a long time, and frequently 
ulcerates ; ultimately, however, heals, and leaves a rose-colored or 
white eschar. Although, in large moles, this process is not capable 
of destropng all the pigment, still it serves to divide them into small 
islands, which, by subsequent operations, may be removed with greater 
ease. 

In children who are already vaccinated, deep pustular ulcerations 
may be produced by a continuous local use of tartar, stibiat., or corro- 
sive sublimate, in the form of a paste or ointment; and, by the time 
these pustules heal, the wdiole mole will be found destroyed. At 
least, the hair-follicles, in those moles that are covered w^ith hairs, are 
destroyed by this means, and their disfiguring appearance is thereby 
considerably diminished. 

In the simple, non-congenital warts of older children, which start 
up in a crop in various places at the same time, all surgical measures, 
cutting, and cauterizing', are totally unnecessary, for they disappear 
spontaneously in the same manner they appeared. The internal use 
of small doses of alkaline carbonates, or of carbonate of magnesia, is 
said to accelerate the disappearance of these warts. 

(12.) Bue:n'S {Combustio). — Burns very often occur in children, 
in consequence of their ignorance and carelessness ; but, when a child 
has once burnt itself severely, there is little danger of the repetition 
of the accident. This fact has become proverbial, that " a burnt child 
dreads the fire." Most frequently the children burn themselves about 
the upper extremities and face, ordinarily on hot utensils, or with 
hot liquids, milk, water, or soup. The severer grades of burns, charac- 
terized by total or extensive destructions, with the formation of scabs, 
are for this reason rare. We seldom see any thing more than the 
formation of blisters. 

Suppuration, however, is also severe and protracted even after 
this inferior grade of burns, and the cicatrices are very much disposed 
to become contracted. In extensive burns, a severe reaction and vio- 
lent fever come on as early as the second day, and in nervous chil- 
dren these Avill be accompanied by convulsions. Usually the general 



518 DISEASES OF CHILDREN. 

symptoms are not very ^dolent, and, under proper treatment and po- 
sition of the burnt part, disappear after a few days. 

Treatment. — The local treatment is conducted according to the de- 
gree of the burn. The pains of simple erythematous hums are most 
quickly allayed by inunctions of lard and covering the part mth cot- 
ton wool. Cold is advisable only in very small erythematous burns ; 
in extensive biirns, on the contrary, the most experienced surgeons, 
such as Walther, JSTussbaum, and others, consider it dangerous. 

Large blisters should be punctured with a fine needle, and the 
serum allowed to escape, the epidermis, however, should not be re- 
moved, for it assists the process of cicatrization better than any kind 
of plaster. The best results in these cases are derived from pencilling 
the part with a concentrated solution of nitrate of silver ( 3 ss to vv^ater 
3 ss). But this remedy causes too intense pain vv^here the cutis is 
denuded. When suppuration has set in, simple cerate and subsequent- 
ly lead-and-zinc ointment may be used. Any two opposite surfaces 
when denuded of their epithelium, for example, between the fingers 
and toes, should not be allowed to remain in contact with each other, 
but should be carefully kept apart by interposing pieces of adhesive 
plaster or lint smeared with cerate. 

The diarrhoea wliich sometimes comes on in extensive burns should 
be controlled by opium. The treatment of the general symptoms 
should be antiphlogistic. For the continuous restlessness and sleep- 
lessness, opium is, once more, the sovereign remed}'. 

In deep burns of the hands and arms, marked contractions of the 
tendons result from the cicatrizations, and an effort should therefore 
be made, by the aid of counter-extending apparatus, to prevent them. 

(13.) Co:n^gelatio, Feost-bite, Chilblain. — So long as children 
are unable to w^alk, freezing of the extremities does not readily occur. 
But, if they are exposed for a long time at this tender age to a low 
temperature, general cyanosis comes on, and they very quickly fall 
asleep to wake no more. Indeed, this criminal practice is probably 
performed oftener than the authorities become aware ; for it is scarce- 
ly possible to prove it by a post-mortem examination. 

In winter, chilblains are of very frequent occurrence in older chil- 
aren who play a great deal in the snow, and have little respect for cold 
and wet feet. Here, as in burns, three degrees are distinguished. 
First grade : redness, slight swelling, itching and pricking, especially 
in chilblain. Seco»nd grade : bloody blisters, which in part originate 
through the influence of cold, but in part also from pressure of the 
shoes, and therefore occur predominantly on the heel and toes. Third 
grade : gangrene of the skin or of entire extremities. The first two 
are the principal grades which occur in children. 



DISEASES OF THE SKIN. 519 

Treatment. — Gelatio of the first degree, wiien still fresh, is best 
treated by rubbing it for a little while with snow. If it has already 
existed for some time, it is no longer possible to remove it quickly, 
and the evil, as a rule, is too slight to make it necessary to subject the 
children on that account to a treatment of several weeks' duration. 
Chilblains usually disappear spontaneously as the spring of the year 
sets in. The greatest benefit has been derived from pencilling the 
parts Avith a solution of nitrate of silver or iodine, especially where 
the itching is intolerable. Various kinds of fat and ointments, equal 
parts of tallow and brandy, etc., and particularly cabinet-maker's glue, 
from which some very striking efi'ects may sometimes be seen, are 
some of the most popular remedies. 

The active discolored ulcers which originate from the bloody blis- 
ters of the second grade, resist the treatment for a long time. It is 
frequently necessary to cauterize them, and to treat them with diges- 
tive ointments until healthy granulations appear on a level with the 
skin. All pressure, of course, must be avoided. 

These are the most important diseases of the skin which in form 
or treatment vary from those of the adult. All others, for example, 
favus, icthyosis, pityriasis, lichen, zoster, urticaria, peliosis, etc., are 
similar in character to those of the adult, and for this reason merit 
no further attention here. Some of the cachectic cutaneous afifec- 
tions will yet be specially treated of in the section on scrofula and 
S}"philis. 

The original plan of this work was, that it should also contain a 
chapter devoted exclusively to the diseases of the organs of locomotion, 
of the bones and muscles. But on more accurate examination it was 
seen that the greater part of them require purely surgico-orthopedic 
relief, and the specialists who have written upon this subject have al- 
ready produced a very extensive literature. We would, therefore, have 
to be either very minute or content ourselves with merely furnishing a 
a simple extract from the writings of the later surgeons and numerous 
orthopedists, and for that reason prefer to refer the student at once to 
these authors. To this chapter would belong defect and malforma- 
tion of the hands and feet, talipes equinus, varus and valgus, curvatures 
of the spinal column, traumatic luxations, and fractures. 

The morbid alterations of the bones produced by scrofula and ra- 
chitis will be described with the cachexise. 



520 DISEASES OF CHILDREN. 

CHAPTER YIII. 

GENERAL DISEASES OF THE SECRETIONS. 

CACHEXIA. 

(1.) Rachitis, Rickets, Ej^glish Disease, Double Limbs. — By 
rickets is understood a developmental disease of the skeleton, in wkich 
a diminution of the calcareous constituents of the bones is the princi- 
pal symptom. The earliest definite descriptions of rickets date from 
the middle of the seventeenth century, and were given by the English 
physicians Whistler^ Boot^ and Glisson. About this time reports of 
a new disease were heard from various parts of England, and a com- 
mission, consisting of the physicians just named, was appointed to 
investigate it thoroughly. 

Since that time but little has been added to our knowledge of the 
pathology, or causes, or varieties, of rachitis, till some fifteen ^^ears ago 
JElscisser discovered the rachitis of the skull. The pathological anatomy 
has been considerably enriched and elucidated since then by the re- 
searches of Kolliker^ Virchoic\ and JSermann Meyer. 

Pathological Anatomy. — For the purpose of coiTectly comprehend- 
ing the rachitic alterations, it is necessary briefly to recapitulate the 
physiological growth of the bone. Every tubular bone grows in length 
and thickness. It grows in length by new layers of cartilage-cells 
which constantly form between the epiphyseal cartilage and the bone, 
in which calcareous salts are then deposited. It grows in thickness by 
the addition of new layers of bony substances immediately beneath 
the periosteum, from the tissue by which the latter is cemented to the 
bone. As the growth in thickness is much more insignificant, and 
progresses slower than that in length, the disturbances of the physio- 
logical growth at the cartilaginous ends are also more striking and 
liable to occur. 

While the bone is enlarging externally in every direction, by the 
addition of new elementary tissue, the medullary space within it also 
increases in circumference. Thus we have a constant new formation 
of bone externally, an absorption of bone internally. The femur of a 
child may with ease be put into the medullary canal of the same bone 
of an adult, so that, by the time the child has grown up, the original 
infantile bone has been completely reformed. 

The physiological growth of a bone consists, then, in — 

(1.) New structural cell-elements deposited on its upper surface. 

(2.) Their prompt ossification ; and in 

(3.) Absorption taking place in the centre of the bone. 



GEXERAL DISEASES OF THE SECRETIONS. 521 

Racliitis consists in the suspension, or in the imperfect performance 
of the second function or process, while the first and third remain 
normal, by which various very striking and peculiar alterations in 
color, form, and consistence, become perceptible. 

In regard to coloi\ the rachitic bone is particularly distinguished 
by a dark-red color, which, on the skull, may even assume a bluish 
redness. The more livid the bone, the greater, as a rule, has been 
the duration and the degree of the rachitic disease. All the bones of 
the same skeleton are not always reddened in an equal degree, some 
are darker, others again are brighter in color, and from this alone it is 
readily seen that rachitis is no simple chemical process, but is due to 
a complicated anatomo-physiological condition. 

No rachitic bone retains its normal form. All the sharp angles of 
the bone become rounded off, the tubular bones in all cases become 
shortened, they cease to grow in length, the epiphyses swell and be- 
come bulbous, a condition which is most plainly seen on the sternal 
ends of the ribs, which are curved in various directions. On the 
tubular bones, for example, on the ribs, simple curvings occur, but 
very frequently actual fractures, or, more correctly speaking, contor- 
tions of the bones occur, especially in those of the lower extremities. 
In advanced rachitis the external layers of the bones, as we will show 
more in detail in the delineation of osseous derangements, contain so 
little calcareous salts, that they cannot be completely broken. 

The internal parts of the bone lying next to the medullary canal, 
formed before the appearance of the rickets, may, it is true, break, 
and do indeed very frequently break, owing to their attenuation, in 
consequence of the absorption that goes on within. The external 
portions of the bones, however, yield, and, though they bend, still do 
not break, and therefore no displacement of fractured ends can take 
place. The bones that are bent, after the manner of a quill or willow- 
twig, subsequently heal with a blunt angle. This bending of rachitic 
bones, and the subsequent angular deformity, may result from the 
action of the flexor muscles and from the superincumbent weight of 
the body. 

The apex of the angle thus formed in the forearm looks outward 
and forward, that of the arm almost straight outward, that of the 
thigh forward and outward, and that of the tibia, which usually bends 
near the ankle-joint, straight forward. 

When such an infraction is sawn through longitudinally, after 
complete recovery, compact substance will be found on the convex 
surface only, and on the concave a broad layer of spongy substance. 
The medullary canal is completely closed at the point of fracture, by 
thick bony extuberations, which subsequently become attenuated, 



522 DISEASES OF CHILDREN. 

though they never disappear entirely. We shall speak more minutely 
of the alterations of form of the individual parts of the skeleton when 
we come to treat of symptomatology. 

The diminution of the consistejice of rachitic bones is very remark- 
able. Incisions may be made several lines in depths and, when the 
disease is much advanced, the bones may even be cut through en- 
tirely without any very great exertion, and without notching the 
knife. These are the coarser anatomo-pathological signs of a rachitic 
bone. 

When the affected skeleton is subjected to a closer examination, 
the following alterations, more or less marked on all the bones, will be 
found : the periosteum is thicker than usual, of a milky opacity in 
many places, and of a rose-red color. On attempting to pull it off, 
small and sometimes large fragments of bone will remain adherent to 
it ; the bone is always dark red, and has a particularly rough external 
surface. This state of the periosteum is most distinctly seen on the 
frontal bones in craniotabes. The skull, in this case, is sawn, or may 
even be cut through with the knife, mth the greatest ease ; and on its 
posterior parts it is impossible to use the saw, for the spots, that have 
become attenuated to the thickness of a card, will yield, become de- 
pressed, and irregularly torn by the saw. From the section through 
the frontal bones, small drops of bloody serum exude ; from the sec- 
tion of the temporal and parietal bones there will be less, and from 
that of the occipital there will not be the least of such serum. The 
frontal bones are always slightly thickened, sometimes to twice their 
normal thickness, and the anterior portions of the parietal bones in 
contact with the coronal suture partake in this thickening ; while the 
posterior portions, on the other hand, are quite as often attenuated 
as in the normal state. Toward the lambdoidal suture, both it and 
the occipital bone become membranous in spots, which are of a 
yellowish-red color. The other parts of the bone which are not en- 
tirely wasted become extremely thin, of a bright color, and totally 
devoid of diploe. By holding the cranium up toward the light, the 
extent as well as the degree of this rachitic thinning, the craniotabes, 
is clearly seen. 

If the calvarium is examined on its inner surface, numerous de- 
pressions are found, entirely on the occipital portion, answering to the 
impressiones digitaim^ each one of which corresponds to a cerebral 
convolution, whose pressure produced the attenuation of the bone, an 
atrophy indeed of the osseous substance. Finally, the dura mater 
and pericranium are in contact with each other, by which, in the 
dried preparation, the osseous tunics simply appear to be pierced and 
the membranes left intact. In these membranes, which resemble the 



GENERAL DISEASES OF THE SECRETIONS. 523 

dried fontanel, some ^vhite opaque points are still occasionally to be 
seen, whicli, on close examination, prove to be masses of unabsorbed 
calcareous mater. Elsiissei^ in his treatise on " The Soft Occiput," 
delineates a calvarium with nearly thirty apertures. Such a specimen, 
however, must be looked upon as one of the most extreme instances. 
The pericranium is, where it is stretched over the apertures, as well as 
in their vicinity, opaque and hypertrophied (PI. VI., Fig. 4). 

The pathological history of the soft occiput is: (1), one of de- 
ficient deposit of the usual phosphates in the external osseous layers 
of the entire bony skull ; and (2), of absorption of those portions of 
the bone which have been softened by the pressure of the weight of 
the brain. 

On the epiphyses of the tubular bones, additional characteristic 
signs may be observed, ^^lien a longitudinal incision of the articular 
head of a long bone — the femur, for example — is made, a thicker 
layer of cartilage is seen than in the normal condition (PI. YI., Figs. 
l-3a), and the line between the bone and cartilage, instead of being- 
straight, is very irregularly indented and undulating (PI. YI., Figs.. 
1-3 b). The apices of the undulations which jut out from the bone 
into the cartilage are intensely injected, and contrast strongly with 
the bluish cartilage. The microscopical and chemical examination of 
the broad, bluish transition-layers, between the bone and cartilage, 
proves conclusively that it is a bone which has been retarded in its ossi- 
fication, in which no bone-corpuscles at all, and but few traces of cal- 
careous deposits in particular, are found. 

On the diaphysis of the tubular bones equally marked alterations 
take place. The periosteum is materially thickened, and cannot be 
pulled off smoothly from the bone. Some fragments of porous bone 
are always torn off with it, and adhere to its inner surface. Imme- 
diately beneath the periosteum, broad whitish or reddish layers are 
found, which present a fine porous, pumice-stone-like structure. 

The trabeculee of this mass, according to Yirchow^ stand like per- 
pendicular radise upon the surfaces of the bone. Deeper still, these 
radise are seen to be interrupted, first by a white and dense line of 
cortical layer, which is parallel with the upper surface of the bone. 
Then follows a new stratum of the same material, of a reddish color, and 
with stronger radise, which are again intersected by a compact parallel 
layer, Thus these layers alternate with each other a variable number 
of times, but the radiag of the spongious layers constantly grow thicker, 
the nearer they approach the medullary canal, and their interstices 
become larger and redder, while the parallel layers become denser 
and firmer. 

The rachitic tubular bone is softest and most porous directly be- 



524: DISEASES OF CHILDREX. 

neath the periosteum, and constantly grows firmer toward tlie centre. 
The hjq^ertroiDhy of the periosteum, and the softened condition of the 
external layers, explain also the singular process of infractions, and 
the impossibility of detecting actual displacement of the fragments 
and crepitation. These are the most important statements concern- 
ing the pathological anatomy of these bones. They are exhaustively 
and thoroughly depicted by 'VircJiow in his Archives, vol. v. 

The chemical examination of rachitic bones has always shown a 
marked diminution of the phosphates and carbonates of hme ; the cal- 
careous salts, instead of constituting two-thirds, often only forming 
one-fifth of the dried bone. In the urine, on the contrary, the phos- 
phates are found augmented from three to five fold. 

This increase of the phosphates in the urine, and its diminution in 
the bones, are not to be regarded as a process in which the calcareous 
salts already deposited in the bones are redissolved, and then ex- 
creted by the kidneys. The salts once deposited in the bones remain 
in them ; a small quantity only may, as a result of the absorption that 
occurs in the parts in the immediate vicinity of the medullary canal, 
again come into circulation. The new enlargements in the longitudi- 
nal and transverse diameter of the bones, however, do not receive any 
more calcareous salts, and the salts of lime introduced with nutriments 
find ho consumption in the organism, but are immediately excreted by 
the urine. 

W^hy the deposit of calcareous salts in the bones ceases is still en- 
veloped in complete obscurity. It is certain, however, that it is not 
a simple chemical redissolving of the already-perfect bone by an acid, 
for otherwise its structures would, both on the periphery and in the 
centre, be alike deprived of calcareous salts, which is certainly far 
from being the case. The layers immediately adjacent to the medul- 
lary canals are much more compact and richer in salts than those of 
the periphery. 

If the skeleton of a child who has recovered from rachitis be ex- 
amined, the bones will still be found curved in various degrees, the 
skull large, its sinciput hypertrophied, and the individual bones are 
remarkably heavy. All the soft, spongy, bony masses that have 
formed during the rickets have become converted into dense, com- 
pact osseous structure, and this subsequent ossification exceeds in 
hardness even the normal bone, on account of which they have also 
been called sclerosis, and in extreme cases even eburneatio. 

No constant alterations are found in the rest of the organs, but the 
lungs, in all cases of marked rickets of the thorax, exhibit acquired 
atelectasis, and severe bronchitis, already spoken of in detail in the 
chapter on pulmonary affections, page 298. The muscles are pale and 



GENERAL DISEASES OF THE SECRETIONS. 525 

flabby, and in various places, especially in the heart, reveal fatty de- 
generation. The liver often display's a decided augmentation of fat. 

Symptoms. — Rachitis is a tolerably acute affection, and generally 
appears on the head first, and always before the close of the first year 
of life. Next in frequency it is seen in the ribs, noticeable several 
weeks after commencing rachitis of the skull, and, lastly, in the lower 
extremities, the pehds, and spinal column. 

Formerly an especial prodromatory stage was assumed, and to it 
disturbed digestion, acidity of the stomach, and defective condition 
of the excretions, with general malaise, w^ere supposed to belong. On 
the other hand, however, it should be borne in mind that the com- 
mencing peiiod of rickets was entirely unknown before the discovery 
of rachitis of the skull by Elsclsser in 1843, and that mostof the signs 
of the so-called prodi'omatory stadium are now seen to be prolonged 
far into the disease itself. 

Rickets is a visible and comprehensible disease, and it is therefore 
necessary to investigate more minutely the alterations of the individ- 
ual parts of the body which result from it during life. 

A.—BACEITIS OF THE SKULL. 

Rachitis of the skull, wdth its peculiar phenomenon — softening of 
the occiput — was discovered by Elscisser. It is worthy of remark that, 
previous to the publication of JElsdsse^'"^ s w^ork, no physician had any 
idea of this extensive morbid condition of the occiput, though it is one 
easy of examination and of detection. Neimiann, for example, says 
that the bones of the head never soften through rachitis ; on the con- 
trary, they often grow at the expense of the other parts of the body. 
Miescher says that all the bones soften except those of the head. 
Various other remote alterations are indeed likely to originate about 
it, such as increased growth above the usual dimensions. ScJuiitzer 
and Wolff say that the bones of the skull never soften ; they even 
grow, apparently at the expense of all the other parts. 

The following are some of the alterations which occur about the 
rachitic skull : 

The anterior fontanel, w^hich, in normal children, closes at the 
latest at the end of the second year, remains open three to four years, 
and may even remain cartilaginous up to the sixth year. The serrated 
suture, which otherw^ise w^e find closed by the end of the first j^ear, is 
frequently still ununited in the third year. The coronal suture, in- 
stead of being united in four months, remains open at the end of two 
years, and the lambdoidal, instead of being, closed at three, is still 
open at the end of fifteen months. Rk/z has instituted accurate 
measurements of the skull, and found that the longitudinal and the 



526 DISEASES OF CHILDREN. 

transverse measurements exhibit but sliglit deviations from the normal ; 
but the pecuHar angular projection of the protuberances of the frontal 
and parietal bones robs the sinciput of its usual globular form, and 
gives it a quadrangular, clumsy shape [tete carree). 

After recovery from the disease, a depression usually forms along 
the course of the coronal suture, which gives to the sinciput, when 
seen from above, the form of a calabash, and is due to an hypertrophy 
of the frontal bones. Numerous depressions and elevations in general 
take place during rachitis, which opens a wide field of research for 
cranioscopy. 

The soft occiput is met with in children from the third month on, 
but is seldom seen in those who have passed the second year. No 
constant prodromata are observed. Many children may have, indeed, 
been previously subject to a bronchial or intestinal catarrh ; others, 
however, have enjoyed the best of health, and, up to the appearance of 
the craniotabes, were well nourished, fresh, and hale. 

The disease begins with profuse cephahc perspiration, which often 
soaks through the pillow, and a nocturnal restlessness, increasing gra- 
datim, becomes noticeable at the same time. Children, who otherwise 
sle^^t uninterruptedly for several hours, vv^ake up every quarter of an 
hour crying, and rub and bore the head into the pillow. Changing 
the posture of the head quickly tranquillizes them, but only for a short 
time. The incessant rubbing of the head on the pillow produces a 
complete alopecia of the entire occiput. 

After some time the whining and discontentedness gTow worse, 
extending even to the daytime, and attentive nursery-maids soon 
notice that the discomfort is subject to the varying positions of the 
head. The patients cry, and constantly bore the head when they are kept 
horizontally, or on the arms while being fed, or put to sleep, but soon 
become quiet when they are raised up and the occiput is relieved from 
all pressure. They then take their food with the greatest comfort, and 
prefer also to lie mth the face resting upon the nurse's shoulder, and 
the occiput entirely free. Older children occasionally quickly turn 
over in bed on the belly, and lie with the forehead pressed into the 
pillow. 

The feeble gro^vth of the hair in general, and the alopecia of the 
occiput, are very noticeable, and, on closely inspecting the skull, the 
occiput is generally found flattened and the protuberances more angu- 
lar than usual. For the purpose of a more accurate manual examina- 
tion, the occiput should be taken upon both hands and felt of with the 
ends of the fingers. 

I examine the whole posterior region of the head, from the lamb- 
doidal angle to the mastoid process, tivice carefully by the ends of the 



GENERAL DISEASES OF THE SECEETIOXS. 527 

fingers. The first time, for the sake of precaution, I exercise only a 
very mild pressm-e ^Yith the flat, open fingers, so that, in case large, 
very soft places exist, no great violence may be done to the unpro- 
tected brain. The second time, I bend the fingers at the point a little, 
and press forcibly upon every part of the occiput and parietal bones. 
By this procedure even the mintuest point of attenuation marked by 
depressibility may be discovered with certainty. 

The soft places generally vary in size from that of a lentil up to 
that of a bean, and are found in the vicinity of the lambdoidal and pos- 
terior portion of the sagittal sutures, and sometimes encroach upon the 
sutures. The external occipital protuberance only is always spared. 
The diseased parts of the bones are elastic, their original convexities 
may be converted into equally as great concavities, and, when pressed, 
yield like a card when laid across a hollow, or like an inflated dried 
bladder. The pain attending a careful examination is not very great. 

The most frequent complications of this afi'ection are spasms of 
the varying groups of muscles. The most dangerous of these is spasm 
of the glottis, whose undoubted yet by no means physiologically 
explained connection with craniotabes has already been discussed in 
detail on page 274. 

Besides attacking the occiput and the sinciput, rachitis invades the 
jaws. The teeth cease to grow, so that the patients get to be twelve 
and eighteen months old before they cut the first incisor teeth. After 
these have finally appeared, they turn black, and, for want of enamel, 
crumble do^vn. When the enamel is totally wanting, the whole tooth 
down to the margin of the gum will disappear ; sometimes it is only 
deficient on the apex, and the blackness is then restricted to that point. 
As the disease disappears before the second dentition commences, 
these phenomena are not observed in the permanent teeth. 

Deficiency of the enamel, now and then met with in older children, 
is, according to the statements of some authors, due to the use of mer- 
curial preparations, especially calomel. Should it actually be statisti- 
cally demonstrated that the majority of these children had taken calo- 
mel, it would, very properly, in future, much restrict the use of this 
medicine. 

^.-RACHITIS OF THE THORAX. 

Glisson and his contemporaries correctly recognized the rachitic 
process, in the condition known as pigeon-breast, and subsequent au- 
thors devoted much of their time and attention in investio-atino- the 
manner of its origin ; we therefore have much more explicit data con- 
cerning rachitis of the thorax than of craniotabes. 

It usually comes on somewhat later than softening of the occiput, 



528 DISEASES OF CHILDKEX. 

and many cliildren who fortunately escaped the latter, and are already 
being carried about upright, are attacked by rachitis of the thorax. 
Perceptible alterations are seldom observed in children under six 
months, while craniotabes may be ^^resent as early as the third month 
of life. The statement made in some of the text-books, that the pigeon- 
breast occurs from the first to the. fourth year of life, is to be under- 
stood as m^eaning that children so old as four years may be observed 
with this disease. But, after the completion of the first dentition, 
rachitis never comes on in a child hitherto perfectly healthy. 

The first symptom of rachitis of the ribs is a marked pain on touch- 
ing or pressure of the thoracic walls. Nurses say that " the child cries 
every time we raise it up, if ever so tenderly." Usually such statements 
are not much heeded by the phj-siciau, because most of them are based 
upon prejudice and incorrect -views. The frequency of these com- 
plaints, however, struck me long ago, and I have convinced myself 
that it is by no means a rare occurrence that children between five and 
ten months old suddenty cry out in pain when they are grasped with 
both hands under the axilla? and lifted up, and, as soon as they are 
laid down, become tranquil again. Nay, more, it is not even necessary 
to lift them up ; slight pressure with the finger in the axillae or on the 
thoracic walls generally, suffices to produce pain. If such a child is 
tenderly raised with one hand under the pelvis, and the other support- 
ing the neck, it will remain as quiet as if it had been Ipng on the 
pillow, and in this manner, also, its bedding may be changed without 
giving it any pain. 

At this time, little or no hypertrophy can be felt at the sternal 
end of the ribs, the boundary between the costal cartilages and the 
bone. The sternal ends of the ribs do not begin to appear bulbous 
and hypertropliied, so as to be detected by the finger, and later also 
by the eye, till after several weeks. Thus two uniform rows of buttons, 
the so-called rachitic wreath, appear on both sides of the thorax at a 
point corresponding to the end of the costal cartilages. These buttons, 
so palpable from Avithout, project still more internally, forming large 
angular tubercles which encroach upon the cavity of the thorax. 

The thorax always becomes deformed in those cases where these 
hypertrophies have existed for some time. The sternum, which like- 
wise undergoes softening, is pushed off more and more from the spinal 
column, and arches outwardly ; the xiphoid cartilage becomes extreme- 
ly movable, and, projecting, forms a deep pit in the scrobiculo cordis. 
In the severest grades of pigeon-breast, the costal cartilages imme- 
diately behind the sternum run straight backward to meet the elon- 
gated transverse processes of the spinal column, and thus, at their an- 
terior ends, the ribs form a conca\ity instead of a convexity. 



GENERAL DISEASES OF THE SECRETIONS. 529 

The diameters of tlie tliorax become smaller from side to side, and 
larger antero-posteriorlj, as is shown by the delineation, PI. V., Fig. 
2. The transverse diameter of the thorax assumes the shape of a 
pear, whose apex is supposed to be at the sternum. The rachitic 
wreath is found chiefly from the second to the eighth rib, the false 
ribs are forcibly pressed outward by the liver on the right, and by the 
stomach and spleen on the left side. The abdomen, in consequence 
of the constant tympanitis, and a shortening and curving of the spinal 
column, is tumefied, and of globular form, and much encroached upon 
by the distorted thorax. The spinal column is curved most during 
the sitting posture, and the globular shape of the abdomen is also on 
that account most striking in this position. When these children are 
laid upon the belly, and in this position raised ujd, the external curva- 
ture of the s^^inal column disappears entirely, and assumes again its 
normal form. In neglected cases, and where the rachitis has existed 
for several years, a permanent arching — ^not an angular curving — of 
the dorsal vertebrae, laterally and posteriorly, may take place. 

The origin of the pigeon-breast is explained, in part, by pressure 
of the atmosphere upon the soft ribs, and, in part, by the traction of 
the diaphragm, for which they serve as points of attachment. Having 
lost their firmness, the ribs are no longer able to withstand the con- 
stant dragging inwardly by the diaphragm. 

From rachitis of the thorax there originate (1), an alteration in 
the curve of the ribs j and (2), an arrest in the longitudinal grovnth 
of the Tibs^ a still more serious result, which inevitably diminishes the 
pectoral space^ and promotes that disease of the lungs known as ac- 
quired atelectasis, as has been already conclusively shown on page 299. 

The prognosis depends exclusively upon the aifection of the lungs. 
When a great portion of them is involved in the atelectic process, 
and has become impermeable, then, of course, a serious catarrh in the 
remaining normal tissue suffices to induce labored breathing, and even 
dyspnoea, suffbcating attacks, and death. In this complication, in fact, 
we have the usual cause of death in rachitic children, as Mo^nherg^ 
Guersant^ and others, have remarked. 

C— RACHITIS OF TEE PELVIS AND OF TEE EXTREMITIES. 

The pelvis does not become deformed before the rachitic child is 
able to walk, and then it is the result of scoliosis, or of an inequality 
of the lower extremities, after the manner of a distortion of the pelvis 
in coxai throcace. The important consequences of this alteration in 
the female are discussed sufficiently in detail in the standard works 
on obstetrics. 

34 



530 DISEASES OF CHILDREX. 

Racliitis of the extremities is first recognized by a bulbous enlarge- 
ment of tbe epiphyses of the radius and ulna at the wrist-joint. Its 
appearance at these points is at a somewhat later date than at the 
ribs, usually during the last months of the first year of life. The degree 
of the rachitic afi'ection is always most distinctly recognized at the 
wrist-joint, because here the epiphyses, in the normal condition, are 
distinct^ seen, and, on account of being superficially situated, are 
easily examined. 

In the cadaver, the lower extremities are found as severely afi'ected 
v\dth rickets as the upper ; but, smce important hypertrophies about 
the knee and ankle-joints occur even in healthy children, rachitis pro- 
duces in them no such striking alterations of form as are seen in the 
wrist-joints. Of course, if the disease has reached the stage of deform- 
ity, the rachitis of the lower extremities Avill also be recognized in 
the gait, and it will not be necessary to even undress the child to see it. 
The protuberances on the ends of rachitic long bones in reahty repre- 
sent their longitudinal growth. New cartilage is constantly formed 
on the epiphysis ; but no ossification of the newly-deposited mass 
takes place, and thus the soft cartilage is pressed out by the con- 
tiguous bone, and by the traction of the muscles into unnatural 
breadth. Hence the bulbous enlargement constantly increases, for 
new cartilage is continually deposited. 

A comparatively diminutive state of all the cyhndrical bones re- 
sults from this cessation of the longitudinal gro^vth, and is most evi- 
dent perhaps in the ribs, and resulting, as has been stated, in the pro- 
duction of the acquired atelectasis. The shortening of the lower ex- 
tremities is still noticeable years after recovery from the rickets, and 
such children are always smaller in stature than their healthy com- 
panions of the same age. 

The simple curvatures straighten again in the course of years ; 
the pigeon-breast may dilate again completely, and the crooked ster- 
num may become straight. The infractions, however, leave behind 
them alterations of form which are permanent. 

As regards the functions of the rachitic lower extremities, they 
are very much retarded. Such children do not learn to stand till the 
second or third year, and to walk still later. Occasionally it happens 
that children, who were able to stand before they were attacked by 
rickets, do not recover this ability until many months later. 

Few diseases interfere -with a child's use of its limbs for so long a 
time as rickets. Children may have been ever so sickly, in the first 
year of life, from almost any other disease, but, so soon as they rally, 
if they do not become rachitic, connnence to acquire the use of their 
limbs, and at eighteen months, at the latest, begin to stand. 



GENEEAL DISEASES OF THE SECRETIONS. 53I 

I Tvas once able to observe accurately the origin of the infractions. 
A cliild, four months old, was attacked by convulsions. I carefully 
examined its body, and found all the tubular bones straight ; still a 
rachitic wreath and hypertrophied epiphyses at the wrist-joints were 
perceptible. During the night the convulsions grew worse, and on 
the following morning one forearm and one tibia, both at the lower 
third, were bent at an obtuse angle, and the parts around were some- 
what swollen and excessively painful. The fractured ends, of course, 
did not crepitate, nevertheless they were movable to a high degree. 
The denomination " fractured ends," strictly speaking, is not applica- 
ble to this condition, for no complete solution of continuity, but only 
a simple bending of the bones, occurs. 

Besides these especially characteristic signs of alteration of the 
bones, others no less constant also occur in other organs. "With the 
appearance of the rickets, or some time before, excessive cephalic, 
and afterward general perspirations, invariably come on, as a result 
of which numerous affections of the skin become developed. Actual 
sudamina, or, still oftener, the so-called sudamina rubra, very small, 
opaque vesicles with red areolse, apjDear, and are so close to each other 
that often the entire body and the flexures of the extremities appear 
reddened, rough, and uneven. Later, when the patients begin to 
grow lean, the skin fades in color, becomes covered with a furfura- 
ceous, squamous exanthema, and the secretion of the perspiration 
ceases almost completely. 

The Hgamentous apparatus, especially the capsule of the hip-joint, 
is extremely feeble and relaxed, so that children are able to touch 
their faces with the feet, and have an especial predilection for putting 
their toes into the mouth. 

As relates to the respiratory organs, spasm of the glottis, mention 
of which has already been made, when speaking of craniotabes, very 
frequently occurs, and, in addition, constant bronchitis, which, on 
account of the increasing carnification of some parts of the lungs, 
becomes severely aggravated. 

The digestion may, indeed, remain undisturbed during the entire 
disease, but, when diarrhoea supervenes, the disease, going on in the 
bones as well as in the system generally, becomes materially aggra- 
vated. It is a remarkable phenomenon that even young children, 
laboring under an intense form of rachitis and loss of appetite, tolerate 
cod-liver oil, and during its use get a better appetite and digestion. 

A few words more concerning the connection of the disease under 
consideration with titherculosis and scrofula. Rickets was formerly 
called " scrofula of the bones," and it was regarded as one of the manv 
locaHzations of the scrofulous cachexia. Hufz was the first to prove, 



532 DISEASES OF CHILDREX. 

by the histories and autopsies of twenty racliitic patients, that the 
inaiority of them were not in the least scrofulous, and, since that time, 
we learn more and more to regard rickets as a sui-generis disease. 

Rickets, according to my extensive observation on many hundreds 
of cases, is an independent affection, which, under certain conditions, 
and at a certain age, may almost voluntarily be induced in every child 
— more in one, less in another. Scrofulous children do not acquire it 
oftener than healthy ones : so the fact, as it occurs here in Munich, that 
rachitis and scrofula but rarely occur together in the same person, 
must be accepted as proof that in this country the majority of rachitic 
children are not scrofulous. 

Etiology. — Remarkably few positive data are knoivn concerning 
the causes of rachitis. In a great number of cases, the possibility of 
its beino' inheritable is not to be ignored. I know several famihes the 
children of which, notwithstanding all possible care, and the most 
rational prophylaxis, always become rachitic at a certain age, and 
suffer from it for years. In these cases, the father and mother usually 
display the pecuharly-shaped rachitic head, with its boldly-projecting 
tuberosities of the frontal and parietal bones. Elscisser and others also 
fmmish us many positive instances on this point. The preWous exist- 
ence of s^-philis, on the part of the father, has often been confessed to 
me, though cured. Rachitis in children of v»'ealthy families may prob- 
ably be explained in this manner. 

In other instances it is developed with remarkable rapidity after 
acute diseases, such as measles, pneumonia, intestinal catarrh, etc. 

Of external causes, there is only one that can be maintained with 
certainty, namely, the leant of fresh ah\ and this is unanimously stated 
by observers as the most frequent cause. This also explains the 
reason why rachitis occurs most frequently, and is most intensely de- 
veloped, in the spring of the year, less so in the fall. 

Long confinement in closed and badly-ventilated rooms during 
the winter has caused it. Enjoyment of fresh air in the open street 
or public place in the summer cured it. Rachitis, for the same reason, 
is less frequently met with in southern climates. 

Prognosis. — As> a simple alteration of the bones, rickets is never 
dangerous, and, in many instances, is arrested, and a final recovery 
takes place, after the conclusion of the first dentition. Its comj)lica- 
tions, however, are extremely pernicious, and by these the greater 
portion of the rachitic children are carried off. 

Spasm of the glottis is apt to supervene at the very commence- 
ment of rachitis, when the soft occiput is as yet barely noticeable, and 
destroys the majority of children it attacks. It will be entirely im- 
possible to prevent the degeneration of some pulmonary lobules, if 



GENERAL DISEASES OF THE SECRETIONS. 533 

the racMtis of the thorax makes much progress, for the lungs constantly 
increase in bulk, -vyhile the chest does not expand in proportion ; on the 
contrary, it even becomes smaller by the projection of the sternal ends 
of the ribs inwardly. When this degeneration, or carnification, or 
acquired atelectasis, involves a large extent of lung-tissue, severe 
dyspnoea and a mild catarrhal affection of the remaining normal tissue 
ensue, which almost invariably lead to death. 

Lastly, the curvatures and hypertrophies of the long bones may 
result in permanent deformities, shortening of one or the other ex- 
tremities, contraction of the pelvis, and displacement and serious dis- 
turbances of the functions. 

Treatment. — A countless number of remedies were employed in 
this disease before the introduction of cod-liver oil, and cort. aurant., 
rad. gentian rub., herb, absinth., rasura lig. quassi^e, calam. aromat., 
cinchona, Colombo, and the preparations of iron, were the ones most 
highly recommended. Externally, baths, affusions, and fumigations, 
with all possible aromatic herbs and their preparations, were employed. 
Later, dyers' red (madder) came into use, principally recommended 
by Feiler and Wendt. Part of this red substance, as is known, be- 
comes deposited in the bones, and it cannot be denied that it possesses 
a direct influence upon them ; but the alteration of .color effects no 
increase in the calcareous deposits. 

Meisner believed he had observed that vaccination arrested the 
progress of rickets, but Hufz emphatically, and with justice, de- 
nies it. De la Fontaine entertained the same views with regard to 
scabies ! 

The idea occurred to some that there was a real deficiency of bony 
substance, and they attempted to introduce it through the alimentary 
canal. 'Wurzer experimented in this direction with phosphoric acid 
which proved perfectly fruitless, and lately BeneJce proclaimed phos- 
phate of lime as an antirachitic. The reports of the experiments, 
wherever instituted with it, are not by any means favorable, and it is 
now very generally abandoned. 

Finally, in the year 1824, Schutze^ 8chen7c^ and Tourtual^ in Ger- 
many, called the attention of the profession to cod-Hver oil, while the 
French physicians became acquainted with it five years afterward 
through JBretonneaii^ who was informed of it by a lay person from 
Holland. Since that time the favorable reports of ol. jecor. asell. have 
accumulated in such a manner that all the remedies heretofore used in 
this disease have been supplanted by it. 

A great deal has been disputed concerning the active jDrinciple 
of the cod-liver oil. Some believe that it simply acts as a respira- 
tory remedy through the fat it contains ; others seek its effective- 



534: DISEASES OF CHILDEEN. 

ness in the traces of iodine and bromine, and still others in its oleic 
acids, and the admixture of decomposing particles of liver which are 
found in all cod-hver oils. 

Since the experiments mth pure fat, as well as those with minute 
doses of iodine or bromine, did not produce the desired effect, the last 
view seems therefore to be nearer the true one. 

It is best to give the brown oil pure by itself in increasing doses, 
at first a teaspoonful, later a tablespoonful once or twice daily. Most 
of the children habituate themselves so well to it in a few days that 
they come to look upon it as a delicacy, and will drink several ounces 
of it at a draught, if they manage to get hold of the bottle. Jxcichitis 
may he cured hy the use of cod-liver oil alone, even if the circum- 
stances are in other respects loifavorahle. To be sure, any possible 
improvement in the residence and nutrition will hasten the recovery. 
In this respect the following measures should be attended to : 

Pure, fresh air is, above all things, necessary. In damp houses, 
which in winter are not ventilated for many weeks, children acquire 
rachitis very quickly, and in an intense form, and in these individuals 
cod-hver oil has only a slow and not a constant effect. 

Zealous attention to the skin is to be mentioned as a second im- 
portant adjuvant. The child should be bathed daily in an aromatic 
bath, and, in addition, the curved limbs should be washed every day 
with brandy. 

Most of the young children, even with craniotabes, tolerate cod- 
liver oil very well ; their restlessness is best palliated by douching the 
head with cold water, repeated every two or three hours. JElsdsser 
recommends a pillow for the head, in which a pyriform hole is con- 
structed, with the apex directed downward. It is a great comfort to 
the little patient. On account of the profuse perspirations, rachitic 
children should not be laid upon feather beds, but always on mat- 
tresses of horse-hair, straw, or sea- weeds. 

Children who are still at the breast should be wet-nursed as long 
as possible, but, in addition to that, should be fed with broths. Cow's 
milk is the best nutriment for children up to the third year, and can- 
not be substituted by any other ; it is to be given as plentifully as 
possible. 

During the disease, an orthopedic treatment will hardly ever be 
of any benefit ; not till after it has been cured can the proper machines 
and apphances be resorted to. 

Great rachitic deformities, even in the adult, may sometimes be 
remedied by exsecting an accurately-calculated wedge of bone, and 
applying a proper apparatus. 

(2.) TuBEEcrxosis a>s'd Sceofulosis. — A great deal has been 



GENERAL DISEASES OF THE SECRETIONS. 535 

disputed concerning the distinction between tuberculosis and scrof- 
ula. Some consider these t^YO conditions as perfectly identical ; 
others, again, assert that there is no resemblance "Whatever between 
them. 

It all depends upon the point of view from which the comparison 
is instituted. If regarded from the anatomo-pathological point of 
view, it may be affirmed with certainty that coxarthrocace and scrofu- 
lous inflammations of the joints, spondilitis, the affections of the 
cornea and conjunctiva, otorrhoea, and scrofulous diseases of the skin, 
are not usually due to tuberculosis of the affected parts. But, in prac- 
tice, the physician is continually witnessing the fact that the two 
diseases just mentioned are (1), by no means local troubles, but partly 
alternate with each other, partly occur simultaneously on different 
parts of the body ; (2), that such children are always the progeny of 
tuberculous parents; and (3), that, after the disappearance of the 
scrofulous affections, which usually occurs about the commencement 
of puberty, these persons ahvays become more or less intensely tuber- 
culous. 

In practice, then, the physician cannot do otherwise ; he must as- 
sume the existence of an intimate connection between the two 
cachexise. But the pathological anatomist, who devotes his attention 
more to the morbid products than to their origin, may very well con- 
sider the produced alterations separately. Still, even pathological 
anatomy shows, in very many instances, the material connection be- 
tween the tw^o. In almost all infantile cadavers, which reveal any 
scrofulous lesions, or affections of the bones or lymphatics, there will 
also be found within, generally in the bronchial glands, one or more 
large, yellow, cheesy tubercles, which are to be looked upon as the 
• root, as the starting-point, of the numerous peripheral scrofulous 
affections. 

Having thus established the connection between the two cachexise, 
we may now pass on to their separate consideration : (a), tubercu- 
losis, and (b), scrofulosis. 

A. -THE TUBEBGULOWS GAGEEXIA. 

Since, in the entire plan of this work, the diseases have been 
treated of according to the individual organs, and not according to 
the nature of the pathological alterations, tuberculosis has therefore 
already been frequently discussed ; and, in order to avoid repetitions, 
we refer the student to the former sections. Tuberculosis of the 
lungs will be found described on page 309, that of the bronchial 
glands on page 311 ; of the brain, on page 339 ; of the ear, page 433 ; 



536 DISEASES OF CHILDREN. 

of the mesenteric, on page 157 ; of the kidneys, on page 444; tuber- 
culous peritonitis, on page 219. It remains only to speak of the gen- 
eral symptoms of tuberculosis and of its etiology. The treatment, 
finally, may be comprised with that of scrofula. But it is also presup- 
posed that a knowledge of the general views of tubercles, their origin 
and retrograde formations, has already been acquired by the student. 

Geneeal Symptoms of Tubeectjlosis. — When single organs are 
particularly severely attacked by tuberculosis, the functional disturb- 
ances of that organ will naturally become very apparent, and will 
eclij^se the symptoms peculiar to the cachexia, as is particularly ob- 
served in tuberculosis of the lungs, of the brain, and of the peritonseum. 
Yery generally, however, when the intensity is less boldly stamped 
on a single afi"ected organ, the following tolerably constant general 
symptoms make their appearance : 

The color of the face, in general, is pale, sallow, and anggmic ; the 
cheeks frequently display a unilateral circumscribed redness, which 
disappears after a few hours. Severe disturbances of the circulation 
in the lungs, or very voluminous bronchial glands, may also induce 
serious dyspnoea, followed by death. JMost of the tuberculous children 
bear a painfully-sad expression in their countenances ; the lethargic 
movements of the eyelids and of the globe, the sclerotica of which be- 
comes, markedly bluish, give them an extremely pecuhar appearance. 

The fever, consisting in an increased temperature of the sldn and 
accelerated pulse, is a constant symptom in general tuberculosis. But 
a distinction should be made between the usual frequently exacerbat- 
ing vascular excitement of chronic tuberculosis and hectic fever, which 
comes on in the last stage, and continues until death ensues. AU tu- 
berculous children frequently, especially toward evening, have a hot, 
dry forehead and hands, increased thirst, and a general heightened 
temperature of the skin ; but all of these symptoms disappear after a 
few hours, and often do not recur for weeks. The nutrition of the 
children does not materially suffer from these transient vascular ex- 
citements, and the latter may also disappear entirely if no new tuber- 
culous injuries ensue. 

The case is entirely different with hectic fever. The pulse, which 
at first is hard, later on small and compressible, rises to 15(i beats 
and more per minute. Every evening an exacerbation ensues, but 
no complete feverless condition ever takes place again. This fever 
may last for months, and even years ; in the latter case, naturally, 
it is less intense, but it induces an emaciation down to a mere skel- 
eton, and does not forsake the child until death. Toward the end, 
the temperature of the skin, according to the feel, does not rise in 



GENERAL DISEASES OF THE SECRETIONS. 537 

exact relation to tlie acceleration of tlie pulse ; on the extremities it 
is more apt to sink to below the normal state. 

At the commencement of tuberculosis, or when the sick child is 
not watched long enough by us, this fever is apt to mislead our diag- 
nosis. The vespertine exacerbations may simulate an intermittent, 
but this error soon becomes manifest from the failure attending upon 
the use of large doses of quinine. Occasionally, the diagnosis vacil- 
lates, for several weeks, between acute tuberculosis and typhus fever, 
and this is all the more likely to happen in children, as infantile typhus 
has fewer well-pronounced sjinptoms than typhus fever in the adult. 
Even when the tuberculous pulmonary symptoms are somewhat 
more predominating, it is often a question whether the continuous 
fever may not be prolonged by a pneumonia that runs an irregular 
course. 

The nutrition suffers markedly in all tuberculous children, and an 
alarming emaciation soon ensues, which, however, as a diagnostic 
sign, is of no great importance, as it is also produced by all febrile, 
protracted infantile diseases. Acute tuberculosis of children under 
one year is an exception in this regard. These children retain their 
plumpness almost until death, especially if they nurse at the breast 
of their mother ; but the constant hot skin, and the incessant cough, 
with which a great deal of white froth is expelled from the mouth, 
permit one to form a diagnosis of acute tuberculosis with the utmost 
probability, and the autopsy, in most instances, confirms this approx- 
imative diagnosis. 

When thrush forms upon the mucous membrane of the mouth, in 
older tuberculous children, a speedy lethal end may be predicted, 
almost with certainty. The tongue presents but little that is charac- 
teristic. The appetite is frequently still fair, even when hectic fever 
has already set in ; on the whole, it is not noticeable that these chil- 
dren become less emaciated, and live longer, than others which suffer 
from continuous dyspepsia. Diarrhoeas are frequently observed, but 
not always due to ulceration of the intestines ; in most instances they 
are the effects of simple catarrh of the intestinal mucous membrane. 

The sMn^ in chronic tuberculosis, is never normal ; it loses its 
original smoothness, and becomes flabby and corrugated in conse- 
quence of the diminution of the subcutaneous adipose tissue. A fur- 
furaceous desquamation frequently takes place upon the trunk and 
neck, which disappears for some time, but soon returns again, and 
becomes complicated with pityriasis versicolor. The strongly-desqua- 
mating, denuded spots perspire but little ; the others, however, as an 
offset, all the more profusely. The perspiration, especially about the 



538 DISEASES OF CHILDKEN. 

head, is seen to gather in large drops, wetting the hairs and pillow. 
Conformably therewith, sudaniina are often observed in large num- 
bers. 

General oedema does not occur in simple tuberculosis ; in the last 
stage, however, a slight oedema, about the ankles and dorsum of the 
feet, takes place. In infants, this oedema is a safe cardinal point, for 
it is almost exclusively seen in tuberculosis, and the physical ex- 
amination of the chest usually furnishes no satisfactory signs. Oc- 
casionally, a partial oedema of the face, and of the upper extrem- 
ities, originates, and is due to local derangements of the circulation. 
Greatly enlarged bronchial glands have been observed to exercise 
pressure upon the vena cava descendens, and thus cause stagnation 
in its vascular sphere. 

Chronic tuberculosis either retains its character till death, and the 
patients die from the effects of the fever, of the emaciation, and of the 
exhaustion, or the lethal end is accelerated by miliary tuberculosis 
and acute hydrocephalus. 

The 2^'i^ognosis need not be put down as absolutely fatal, even in 
tolerably advanced tuberculosis, for cases occur in which, notwith- 
standing all the bad signs, an arrest nevertheless ensues, and, after 
many years of sickness, perfect nutrition and progressive development 
finally take place again. 

Etiology. — There is no disease that is so positively inheritable as 
tuberculosis, and this inheritability is so clearly demonstrable, in many 
cases, that I suspect it is the only and true cause of the cachexia. 
True, children bring no ready tubercles with them into the world, and, 
so far as I am aware, none are ever found at autopsies of the new-born, 
but tuberculosis may completely develop itself as early as the first few 
weeks of life ; so that miliary, and occasionally large tubercles are 
found in an infant that only lived two or three months. 

The intensity varies very much in degree, according to the kind 
of constitutions the parents have. If only one of the parents is tu- 
berculous, and the other comes from a perfectly healthy family, then 
all the progeny of this alliance need not necessarily be tuberculous, 
nor even scrofulous. It fares just the same way with the inherita- 
bility of tuberculosis as with the formation of the body. When the 
father has black hair and brown iris, the mother blond hair and blue 
iris, then the children usually have oio mixture of these variegations 
of color ; but, in most instances, a portion of them will take entirely 
after the father, another after the mother. Now, when the father is 
tuberculous, but the mother healthy, or vice versa, it may very well 
happen that a part of the children will be perfectly sound, another 
decidedly tuberculous. Frequently, however, a weakening of the 



GENERAL DISEASES OF THE SECRETIONS. 539 

cachexia, -vrliicli manifests itself by milder scrofulous forms, is observed 
on the one hand, and, on the other, slight scrofulous affections and a 
disposition to bronchitis, chronic blepharitis, and phlyctenular con- 
junctivitis, in apparently perfectly healthy children. 

Now, by " crossings " between strongly tuberculous, feebly tuber- 
culous, and healthy persons, a number of gradations originate ; and in 
the hmitless extent to which the cachexia has now attained, but very few 
families will be found to have remained perfectly free from all dispo- 
sitions to tuberculosis, and from all the scrofulous symptoms which 
point to it. The chief difficulty that has to be overcome, when the 
attempt is made to explain the origin of tuberculosis by the in- 
heritabihty alone, is this, that especially the milder grades of tubercu- 
losis, some circumscribed, perhaps even cretaceous tubercles, are not 
diagnosticable. Yery frequently, in fact, the residue of a former tu- 
berculous jDrocess, of which no one had the least idea, is found in 
the apices of the lungs or bronchial glands, at the autopsies of the 
strongest, best-developed individuals who succumbed to some acute 
disease. Consequently, it is never possible to maintain, with any 
degree of certainty, that there is no hereditary disposition, and that 
the tuberculosis, in a given case, has to be produced entirely by ex- 
ternal causes. 

The following are generally considered the external causations of 
tuberculosis : bad air, confinement in close, imperfectly-ventilated, 
dusty rooms, damp houses, and bad food, by which, living exclusively 
on rye bread and potatoes, and the deprivation of animal food, is un- 
stood. But if any deductions regarding these external causes can be 
drawn from a large poor practice, such as mine has been for the 
last few years, then it becomes pretty evident that tuberculosis is 
very rarely generated by them; and, on the other hand, it is very 
often found where these external causes are entirely absent. 

The circumstances are most strikingly manifest when children of 
different parents grow up in one family, a very frequent occurrence in 
the case of illegitimate children who cannot remain with their mothers, 
but have to be boarded in another family. Now, when the family 
that have taken charge of this child have children of their own, all the 
children mil live together under the same circumstances. They sleep 
in the same rooms, they eat from the same dish, they are alike neglected 
as regards attention to the skin, and yet it is observed scores of times 
that the strange child remains perfectly well, while their o^vn children 
are the whole year through under treatment for scrofulous affections, 
or that the contrary happens to be the case. Now, when these facts 
recur so often that ever}- busy physician is able to count them in large 
numbers, the faith in external causes, unwholesome food, bad air, m- 



540 • DISEASES OF CHILDREX. 

attention to the skin, becomes more than vacillating, since, among the 
great masses of proletarians who live crowded together in large cities, 
tuberculosis would have to be still more frequent than is actually the 
case. Entire houses, and even streets, in which these poor people are 
huddled together, ought to be tuberculous, a circumstance which, so far 
as I am aware, has never been observed in any city. 

These external causes may be of the utmost importance for chil- 
dren who bear the germ of tuberculosis, and increase and aggravate 
the kind as well as the number of the single exacerbations ; where, 
however, the former does not exist, the children certainly develop 
slower, remain pale, lean, and small, yet do not exhibit tuberculosis, 
nor even scrofulosis. • 

Let us consider the affair from the opposite direction. In children 
of the opulent classes these external causes are entirely absent, and 
thus fewer children of the affluent ought to be tuberculous than of the 
poor who may have become so through the unfavorable circumstances 
under which they are situated. But, so far as the general survey 
reaches (these circumstances cannot be calculated by per cents.), if is 
fomid that children of the rich are not less frequently tuberculous than 
those of the poor, nay, more, the disease seems to occur oftener and more 
predominantly in the former class. This view also results in the fact, 
that by far less weight ought to be placed upon bad diet, residence, 
and inattention to the skin, than upon the hereditary disposition. 

Although the external causes are of but slight importance in regard 
to generating tuberculosis in healthy indiwduals, it must nevertheless 
be acknowledged that they become powerful agents where the heredi- 
tary disposition exists. In this respect, however, other preceding dis- 
eases are of more importance, especially measles, syphilis, whooping- 
cough, and typhus fever. After these maladies, tuberculosis suddenly 
develops itself in children who formerly were apjDarently perfectly 
well. It most frequently comes on after measles ; here it is such a 
frequent follower, that the assumption, that no child with an hereditary 
disposition is attacked by measles who does not subsequently become 
tuberculous or at least scrofulous, seems justifiable. This tuberculosis 
following upon measles distinguishes itself, from that of the spontane- 
ously originated, by the fact that an arrest, and finally even a decided 
improvement, is much more frequently observed in it than in the latter 
kind. 

-B.—THE SCROFULOUS CACHEXIA. 

By scrofulosis we understand a series of inflammatory processes 
upon the shiji and inucous onemhrajies, on the organs of sense, sights, 
and hearing, in the lymphatic glands, and on the hones and joints, 



GENEKAL DISEASES OF THE SECEETIONS. 54-1 

whicli, anatomo-pathologically, have no connection lohatever. Tliey 
diflPer materially in their course from simple traumatic inflammations 
of these parts, and seldom occur singly, but in most instances on sev- 
eral parts of the body at the same time. 

Examination of the affected parts alone, even without taking into 
consideration the entire state of the organism, often furnishes such 
peculiarities that the adjective " scrofulosus " may be added to the 
name of the inflammatory process with the utmost surety. This re- 
mark is especially applicable to some of the diseases of the eye, to the 
ulcerating lymphatic glands, and the affections of the bones and joints, 
while most of the cutaneous eruptions, catarrhs of the mucous mem- 
branes, and otorrhoea, can only be recognized as being cachectic by 
the obstinacy of their course and complication with markedly scrofulous 
affections of other organs. 

The opponents of the scrofulous diathesis theory, who obstinately 
shut their eyes against the manifest common and intimate connection 
between the affections just mentioned, fall back upon this argument 
in ]3articular, that the cachexia has not heen shown to he present in 
the hlood. Singularly enough, they forget that, in none of the dys- 
crasias in general, neither in syphilis, nor in carcinoma, nor in tuber- 
culosis, has it been possible to detect any thing specific in the blood ; 
but that general diseases are here in question has been emphatically 
acknowledged by all thoughtful physicians. 

The following principles must be maintained from a clinical point 
of view : 

(1.) There are certain chronic inflammations which have an inti- 
mate etiological connection. 

(2.) Children affected by them are, in greater part, the progeny of 
tuberculous parents ; and 

(3.) These children very frequently become tuberculous after the 
appearance of puberty, even when the scrofulous phenomena have dis- 
appeared long before. 

Scrofula therefore seems to be the commencement — perhaps, also, 
an imperfect development of tuberculosis. According to my observa- 
tions, which, unfortunately, on account of the difficulties attending 
upon the demonstration of tuberculosis in the parents, have never led 
to precise results, it occurs principally in families where one of the 
parents is healthy, but the other tuberculous. Wliere both father and 
mother are tuberculous, most of the children perish in the first few 
years of life, from true tuberculosis, and overleap these milder transi- 
tions altogether. 

As regards the general symptoms of the so-called scrofulous dia- 



542 DISEASES OF CHILDREN. 

thesis, most of the signs classified under it are merety the simple 
effects of the local processes, and do not depend upon any particular 
inherited anomalies of the constitution. This is also the reason why 
the delineation of the so-called scrofulous habitus cannot be com- 
prised in one picture, but must be given in two forms, the erethitic 
and the torpid. 

On close examination it is seen that the description of these two 
forms is reduced to extremely vague statements. Thus erethitic 
scrofulous children are said to have a slender frame of body, feeble 
muscular system, keen comprehensive abilities, delicate formation of 
countenance, fine eyes, bluish sclerotica, and dilated pupils. The tor- 
pid scrofulous diathesis, on the other hand, is said to be recognized 
by coarse features, large head, wide jaws, bloated nose and upper lip, 
reddened eyes, swollen lymphatic glands, and large abdomen. 

In this delineation general constitutional derangements have been 
improjDerly thrown together with local morbid processes. The general 
characters are extremely unrehable, and in addition entirely incorrect ; 
the local, the bloated nose and upper lip, reddened eyelids, glandular 
hypertrophies and tymj)amtic distended abdomen, are indeed local 
phenomena of scrofula, but they are not so constant as to be capable 
of producing the diathesis, and their absence or disappearance is by no 
means proof positive that the children are no longer scrofulous. 

Children may, indeed, entirely get rid of their scrofulous habitus, 
of their adenitis meibomiana, of their tumefied nose and upper lip, 
which, in fact, are only caused by chronic catarrh of the nasal mucous 
membrane and its corroding secretion, and, after several months, again 
acquire the same or other scrofulous affections. So, then, the habitus 
will be present, or not, according as to whether these local inflam- 
mations haj)pen to be present or have disappeared. 

Now, so far as relates to the local processes, they are collectively 
distinguished by a tedious course, frequent relapses, and obstinate re- 
sistance toward all local treatment by cauterizations, cataplasms, and 
ointments of all kinds. The majority of them present such character- 
istic symptoms that they merit a separate consideration. 

(a.) Skin. — Here the discharging eruptions, eczema, impetigo, and 
ecthyma, most frequently occur. 

Furunculosis, which likewise attacks only children of tuberculous 
parents, has already been spoken of on page 512. 

By eczema an inflammation of the skin is understood, in which 
a fluid exudation accumulates beneath the epidermis, and assumes the 
form of small, closely-aggTegated vesicles spread over a large surface. 
An eczema simplex and rubrum are distinguished according as the 
adjoining portions of the skin are strongly or slightly erythematous 



GENERAL DISEASES OF THE SECRETIONS. 54.3 

and tumefied. The name of eczema impetiginodes has been bestowed 
upon a variet J in which the vesicles are larger and filled with pus. 
No particular forms, of course, can be assumed, for all the three forms, 
or, at least, one after the other, may very readily occur in one person. 

Symptoms. — In all cases, when the vesicles and pustules burst and 
dry up, yellow scabs form, which are elevated by the succeeding exu- 
dations, and the previous desiccating processes begin anew in the same 
manner. The crusts on the scalp become much thicker, by agglutina- 
tion with the hairs, than on other parts of the body. The secretion 
occasionally becomes so profuse that large drops of turbid serum ooze 
out from some of the existing cracks and fissures of the crusts, and 
may even flow down. This exudation also corrodes remote parts of 
the sound skin, and upon these a similar suppurating eruption may 
originate. 

Eczema has no special connection either with the glandular or 
with the follicular apparatus, but is a pure inflammation of the cutis ; 
it is most frequently met with in scrofulous children upon the head 
and face (tinea capitis, porrigo), but, after all, does not wholly sjDare 
any part of the skin. After from four to eight weeks, a spontaneous 
recovery usually ensues; generally, no one place suppurates longer 
than half a year steadily. Where it has existed for more than four 
weeks, the adjacent glands will also be found enlarged, especially 
those of the neck ; for, as has already been remarked, eczema most 
frequently attacks the head. These glandular hypertrophies have the 
peculiarity of scarcely ever undergoing suppuration; but, after the 
eczema has been cured, gradually lessen in size, or remain slightly in- 
durated for some time thereafter. 

Eczema heals without loss of substance ; but, on the hairless parts 
afi'ected, a dark discoloration of the skin will remain, which disappears 
after several months. Relapses are of frequent occurrence. 

Treatment. — The local treatment only will be discussed here, 
for the general will follow at the conclusion of the section. Ac- 
cording to my thousand-fold observations, simple cleanliness, and, for 
the scalp, the removal of the hair, are entirely adequate to cure it. 
Even this last procedure is not absolutely necessary ; it, however, ac- 
celerates the desiccation, and is of great benefit to children who are 
extremely annoyed by the agglutinated masses of hair and crusts. 

Vain mothers, however, very unwilHngly consent to have their 
daughters' hair cut off. It is true that children are much tortured 
during washing and combing of the hair, but it cannot be ignored 
that, even in this irrational, at times even cruel, treatment, a period 
finally arrives where no new exudations take place, and a normal skin 
makes its appearance after the dried scabs have fallen ofi". 



544 DISEASES OF CHILDREN. 

The crusts are best removed after soaking them with oil ; they 
thereby become soft, and may be taken away without causing any 
pain. The severe itching of the skin causes the patients to scratch 
themselves incessantly, but this also may be prevented to a certain 
extent by cutting their finger-nails as short as possible twice a week. 

By impetigo we understand an inflammation of the skin in which 
small and large pustules spring up on an erythematous base, and then 
dry up into thick yellow or brown scabs. The exudation goes on be- 
neath the crusts, elevates them, and for some hours the inflamed ce- 
rium lies exposed, but soon becomes covered with new crusts. The 
course, the rest of the symptoms, and the local treatment, difi'er in no 
respect from those of eczema. 

By ectliyyjia and rupia^ large solitary pustules are understood, 
which give rise to temporary brown scabs, and then usually pass over 
into torpid ulcers. In most intances the inflammatory areolae are in- 
significant, but, when the cachexia is very well pronounced, they 
become bluish red. The ulcers that form after the scabs fall off dis- 
charge hardly any secretion ; indeed, are almost dry, but nevertheless 
heal very slowly, and frequently last until death. This eruption oc- 
curs only in emaciated, atrophic children. 

Treatment. — An attempt should be made by the aid of stimulating 
ointments, ung. digestivum, or by lightly pencilling them with nitrate 
of silver, to induce a strong reaction in the torpid ulcers. The local 
treatment, however, remains fruitless, if no constitutional improvement 
can be brought about. The remedies which are indicated will be 
prescribed at the conclusion of the section. 

Besides these vesicular and pustular eruptions, the corroding tetter, 
lupus^ is yet to be described as being pecuhar to scrofulosis. 

Symptoms. — Lupus occurs in children under all the four forms 
which dermatology teaches. We have (1), a X. exfoliata j (2), X. 
tuber osa j (3),X. exulcerans ; and (4),X. serpiginosus^ or amhulans. 

Lupus exfoliatus consists in large and small hypertrophied spots 
on the integument, having glistening ground-off upper surfaces, which 
constantly desquamate, and induce an intolerable itching. In color, 
these hypertrophied spots vary from a rosy to a bluish red. The 
induration is more marked than the projection above the level of the 
normal skin. 

Lupus tuberosus differs from the first form only by the greater 
prominence of the tubercles, which, by aggregation, may swell up 
into large, bluish-red tumors, and sometimes feel hard, but sometimes 
also fluctuate. The desquamation and color are the same in character 
as in the first. 

Lupus exulcerans, also called phagedsenicus, seldom originates 



GENERAL DISEASES OF THE SECRETIONS. 545 

primarily as such, but generally develops itself from one of the forms 
just mentioned. It is characterized by hard cutaneous exudations, which 
rapidly liquefy, and leave behind deep, uneven ulcers. These ulcers 
discharge no pus, but a brownish ichor, and heal extremely slowly. 
They penetrate into the deeper structures, and do not spare even the 
bones. The crusts which, by the diminution of the discharge, form 
from time to time, are usually soon cast o£F. 

Lastly, lupus serpiginosus is distinguished by the formation of 
deeper ulcers, which constantly become larger and larger by the dis- 
integTation of the new exudation deposited in the edges of the ulcer, 
while the parts first attacked contract, become flat, and assume a 
healing action. The cicatrices always remain white, depressed, and 
corrugated, and the loss of substance, especially when the lupus was 
located on the nose or eyelids, is very disfiguring. 

None of these four forms ever occur in the healthy, but only 
in the cachectic, and, in fact, chiefly in well-pronounced scrofulous, 
less frequently in syphihtic children. Their site is preferably in the 
face, most frequently on the nose, next on the cheeks and lips, very 
rarely on the trunk and extremities. 

The course is very chronic, and, in most instances, it takes years 
to cure them ; the loss of substance is always considerable, and the 
cicatrices are visible all through life. 

Treatment. — The local treatment of lupus, especially the corro- 
ding form, is of great importance. It is absolutely necessary to put 
a stop to the progress of the evil by a systematic course of cauteriza- 
tions. Nitrate of silver is not powerful enough for these cases, and 
we have to resort to arsenic or chloride of zinc paste. Dupuytren's 
arsenic powder (ninety-eight or ninety-nine parts of calomel and one 
or two parts of white arsenic) is especially adapted for superficial cau- 
terizations, vv^hen not too near the mouth and nasal passages. The 
ulcer should be cleansed, and the powder applied one-third or one-half a 
line in thickness, over which a layer of gum-arabic powder should be 
spread ; the moisture of the ulcer soon converts the whole into an ad- 
herent paste. After from eight to ten days the paste falls ofi", but, in 
most instances, has to be reapplied several times. 

Chloride of zino paste is less dangerous on account of possible 
poisoning, and none the less efficacious. One part of chloride of zinc 
is mixed with two or three of starch-powder, stirred up with a few 
drops of water, and then applied upon the cleansed ulcer. The chlo- 
ride of zinc corrodes to a depth equal to the thickness of the layer. 
The cauterization has to be renewed, after the eschar falls off, until a 
fine, granulating surface appears. 

Without an internal treatment with cod-liver oil, continued for 
35 



54:6 DISEASES OF CHILDREN. 

years, not even temporary relief will be attained by the most powerful 
escharotics. It is liardly necessary to state that it is not practicable to 
apply the chloride of zinc paste without anaesthetizing the little patient. 

(b.) Mucous Membranes and Organs of Sense, — The morbid alter- 
ations of the organs of sense, with those of the mucous membranes, 
generally are treated together, because in scrofulous affections the 
organs of vision and hearing invariably participate in great degree 
with their mucous membranes. 

The mucous membrane of the mouth and alimentary canal displays 
no characteristic scrofulous affections. Bronchial catarrhs, so frequent 
and tedious in scrofulous children, are much more probably produced 
by actual tuberculosis of the lungs than by scrofula. Likewise in the 
uropoetic system no particular derangements occur; in the vagina, 
however, a tedious leucorrhoea is often observed in scrofulous girls, a 
more detailed description of which has already been given on page 
468. 

Marked scrofulous lesions occur only on the mucous membrane of 
the nose, of the eye, and of the ear. 

NOSE. 

A suppurating eruption, eczema, or imj^etigo, very frequently at- 
tacks the nasal cavities at the place of transition from the mucous 
membrane into the cutis, in consequence of which the former becomes 
hypertrophied, and discharges a large quantity of corroding secretion. 
The nasal cavities are finally totally occluded by the crusts, which con- 
stantly become thicker and thicker ; the tip of the nose swells up, and 
the acrid secretion that flows down over the upper hp produces a 
chronic inflammation and infiltration of the integument of these parts. 
The tumidity of the nose and upper lip is of such frequent occurrence 
that the scrofulous diathesis is usually diagnosticated by it. 

Although it cannot be denied that children so constituted are al- 
ways scrofulous and sufi'er from still other scrofulous affections, never- 
theless it does not follow that those who have no swollen nose 
and upper lip are not scrofulous too. This affection is by no means so 
frequent that it might be identified with the scrofulous diathesis. 

The recovery requires months, and even years, and, when the 
eruption has finally disappeared, the infiltration of the cutis yet re- 
mains for a long time. These simple eczemas have nothing in common 
with lupus, polypous growths, and purulent coryza, or ozsena, nor do 
they generally pass over into such conditions. 

Scrofulous ozsena consists of a bloody, purulent discharge from one 
or both nares, and is distinguished from the affections of the mucous 
membrane just described by the never-absent pungent smell of the mat- 



GENERAL DISEASES OF THE SECRETIONS. 547 

ter that flows from the nose. It is also very tedious, disappears some- 
times for several weeks, and then returns with its former severity. 
In most instances a periostitis of a part of the nasal bones is at the 
bottom of this complaint, and small necrosed pieces of bone are also 
occasionally discharged. Tliis sufficiently explains the intense odor 
and the protracted course. 

Treatment. — Injections of cold water or weak astringents render 
essential service when the children become large and sensible. In 
small children, who obstinately resist these measures, we have to be 
content with the use of a w^eak ointment of red precipitate (gr. iij to 
lard 3 j), introduced into the nose by the aid of a thin bourdonnet. 
Here, also, the general treatment is the principal consideration. 

EYE. 

The Meibomian glands on the lids very frequently ulcerate. Many 
hordeola form, part of which pass over into suppuration, and part into 
induration. The adjacent parts of the eyelid are here swollen, and 
quickly become excoriated in consequence of the accumulated aug- 
mented secretion. This affection likewise lasts several months, and 
often terminates with total or partial loss of the cilise. 

After several days these phlyctenulse burst, the vessels running to 
them atrophy, and soon disappear altogether. When this process is 
completed, no permanent injury to the eye, nor any visible residue, is 
to be observed. But the case is entirely different where the cornea 
has been affected. 

keratitis scrofulosa presents itself either as a simple further de- 
velopment of the vessels of the sclerotic conjunctiva upon the cornea, 
so that radiating vessels run to it at one point, or around its whole 
periphery, or large or small ulcers form at some one point on the 
cornea. 

These corneal ulcers likewise originate from pustules, which cor- 
respond to the phlyctenulse of the sclerotic ; here, however, they burst 
uncommonly quickly, and, in a short time from the commencement of 
the evil, no pustules are to be seen on the cornea, but, instead, a small, 
visible, shallow depression, the result of a loss of substance, around 
which the cornea appears hazy or of a milky opacity. The ulcers thus 
originated, of w^hich several often appear at once, require a long time 
to heal up. The place where they were situated often looks as if 
ground off, but the smoky opacity of the base of the ulcer and its 
\acinity does not disappear for many years, or remains ^^isible all 
through life — macula cornea. 

In strongly cachectic individuals, the ulcers may penetrate deeper 
and deeper, and finally perforate the cornea. If the ulcer was situated 



548 DISEASES OF CHILDREN. 

centrally, so that the perforation, after the escape of the water from 
the anterior chamber of the eye, could not be closed up by the iris, 
phthisis bulbi generally ensues. But if the ulcer was situated more 
peripherally, then the iris prolapses, becomes covered with exudation, 
and the patients recover with a deformed pupil, by which the power 
of vision is but little diminished. At the place of union between the 
iris and cornea, a white spot with a black central point forms, fiom 
Avhich a staphyloma may subsequently develop itself. 

Perforation by the scrofulous ulcers seldom occurs ; on the whole, 
hardly one out of a hundred perforates, and, of those which do, the 
favorable termination of prolapsus of the iris occurs comparatively 
often. 

Slepharospasmus^ spasm of the lids, is very characteristic of scrofu- 
lous inflammations of the eye. It is produced by the great intolerance 
of light, which is absent in a small number of cases only. Children 
will not open the afflicted eye throughout the whole day ; during day- 
light they hide themselves in dark corners and rooms, keep their hands 
before the face, and hinder as much as possible the penetration of 
light into the eye. Although it must be acknowledged that com- 
plaisant, obedient children, after much persuasion, are finally induced 
to open their eyes for a moment, or at least submit to have them 
opened, nevertheless, in other cases, the penetrating light produces 
such violent irritation that the child, with the utmost desire to open 
its eyes, is unable to do it. Such a child may indeed be secured by 
assistants, and the lids forcibly torn apart by the hands, but some 
bleeding from the angles of the eye and swelhng of the lids are always 
produced thereby. 

Therapeutically, this violent tearing open of the lids is of no use 
whatever, for the treatment remains the same whether there are any 
ulcers or not ; a palpable harm, hoAvever, may result from the marked 
swelling and unavoidable bruising of the lids. In regard to the prog- 
nosis, this procedure may be of more importance ; for a perfectty favor- 
able prognosis may be given to the profoundly afflicted parents, when 
none dr only a peripheral ulcer of the cornea can be discovered. 

The intolerance of light is not always in exact relation to the ma- 
terial alteration of the cornea ; the former is often present to a high 
degree, and the latter structure entirely intact. Along with the in- 
tolerance of light there is always profuse lachrymation, and the tears, 
in common with the friction and constant pinching of the eyelids, the 
result of violent contraction of the orbicular muscle, soon produce a 
humid vesicular eruption of the whole moiety of the face. 

Scrofulous inflammations of the eye relapse extremely often — 
it may almost be said, invariably. It takes at least half a year — 



GENERAL DISEASES OF THE SECRETIONS. 54.9 

often, however, many years — before the subjects attain to such a con- 
dition as to properly enjoy hfe again. The violent, continuous pains, 
by which these affections are accompanied, usually produce also some 
fever and loss of appetite, u]3on which a visible emaciation of the 
whole body supervenes. 

There is a very peculiar alteration of the cilise in chronic scrofu- 
lous inflammations. At first they grow to a singular length and 
thickness, but thereby lose their plain, arch-like curve, and become 
undulating, almost curled. Later, all these degenerated eyelashes 
fall out, and are replaced by fine, small, sparsely distributed hairs, 
which remain for life. 

The alternating character of the different local manifestations of 
the cachexia is seen most distinctly in scrofulous ophthalmia. The 
corneal ulcerations may persist for many months, and constantly grow 
worse in spite of all local and general treatment, when, suddenly, an 
eczema attacks the head, or an otorrhoea, or a bronchitis, or a scrofu- 
lous affection of the bones, supervenes, and the obstinate inflammation 
of the eyes is completely gone in a few days. Intolerance of light, 
lachrymation, and vascular injections, have vanished, as if by magic, 
nothing but an opacity of the cornea remains, which, with the ex- 
ception of producing a diminution of the power of vision, has no fur- 
ther bad effects. 

Treatment. — Notwithstanding all rational and irrational, painful 
and painless, old and new remedies, which ophthalmologists have 
recommended in large numbers, there is still no method of treatment 
which notably exercises an aborting and mitigating effect upon the 
course of this pertinacious evil. 

The eyes should not be allowed to be bandaged ; a green shade, 
however, is beneficial. All ointments and collyria are, so long as red- 
ness and pain exist, injurious, and increase the irritation. There is 
nothing better for this inflammatory stage than tepid-warm, distilled 
water, with which the eye may be bathed and irrigated every 
hour. Cold applications, in most cases, aggravate the pains and 
redness. 

The patients should not be encouraged in their efforts to entirely 
avoid the hght. They should be provided with a plain shade — um- 
braculum— and be confined in a darkened room. Some benefit is de- 
rived from dropping into the eye a drop or two of a concentrated 
solution of atropine (gr. j to water 3 ij) several times daily, and 
fi'om the internal use of the extract of belladonna, of which gr. ss. 
may be given in the twenty-four hours. Immersions of the head in 
cold water have a decidedly beneficial effect upon the blepharospas- 
mus ; it is, however, but a few hours in duration. These procedures 



550 DISEASES OF CHILDREX. 

can only be executed under the violent struggles of the children and 
their parents ; and the usual consequences are, that the former are not 
to be found when the time comes for the next immersions. I have 
therefore given up this somewhat brutal treatment for the last few 
years, and I think the results have been quite as favorable. 

When the patients are not intensely tainted with tuberculosis, 
which is not the case, as a rule, they will tolerate inunctions of blue 
ointment very well, and a tolerably good, although not always more 
rapid course, is observed from this treatment. 3ss — 3j of blue oint- 
ment is rubbed in upon the forehead daily, over which a broad bandage 
must be tied, for otherwise the children will smear themselves all over 
with it, and the ophthalmia becomes aggravated if any of the ointment 
gets into the eye. 

Against severe pain, sleeplessness, and general excitability, mor- 
phine will always prove to be the sovereign remedy. I generally cause 
gr. ss. to be dissolved in 3 iij of water, and of this solution give half- 
teaspoonful doses, according to necessity. No bad consecutive effects 
can be perceived from such small doses of morphine ; leeches, which 
formerly were often resorted to, likewise, on account of their pain- 
assuaging effects, may, however, cause much harm through consecutive 
ansemia. 

^Yhen the com^se is an obstinate one, and no cutaneous eruptions 
are present, a rapid, remarkable improvement of the affection of the 
eyes may occasionally be seen from the production of pustules by 
tartar-emetic ointment. The Autenrieth's * ointment, however, is a 
totally inappropriate preparation for the purpose of attaining this end. 
The patients scratch the places where the ointment has been applied, 
and then rub their eyes with the soiled fingers, by which they pal- 
pably aggravate their ophthalmia. For a number of years back I 
have been in the habit of applying to the nape of the neck a mixture 
of one part of tartar, stibiat. and three parts of emplas. citrin., smeared 
upon strips of adhesive plaster to the thickness of the back of a knife. 
At the end of four days the plaster may be removed, when a number 
of pustules will be found to have formed, which may be kept in a 
state of suppuration for a long time by the use of ung. sabinee. 

Against the blepharitis and adenitis meibomiana, desiccating or 
slightly stimulating ointment may be resorted to. Here the white 
precipitate (gr. ij — iv to adepis 3 j) and ung. zinci are especially 
serviceable. 

As has already been observed, all these remedies have no decided 
effect, and the principal procedure is always a year's cgntinued, cir- 
cumspect, general treatment. 

* Ung. antim. et potas. tart. — Tr. 



GENERAL DISEASES OF THE SECRETIONS. 551 



EAR. 

Scrofula fui-nishes the chief cause for affections of the ear, es- 
pecially chronic otorrhceas, the termination of otitis externa and in- 
terna. Diseases of the bones of the meatus auditorius, and of the 
petrous portion of the temporal bone, occur almost altogether in chil- 
dren of tuberculous parents, and are combined or alternate with other 
local affections of the cachexia. The morbid conditions belonging 
here have already been dehneated in detail on pages 427 to 433. 

(c.) Lymphatic Glands and Subcutaneous Gelhdar Tissue. — 
Swellings of the glands are of extremely frequent occurrence in scrofu- 
lous children, in most instances produced by adjacent affections of the 
mucous membrane, or of the integument. The lymphatic glands of 
the neck swell up most frequently ; those of the axilla and groin not 
quite as often. 

Pathologically, a distinction may be made between simple hyper- 
trophy and tuberculosis of the lymphatic glands ; practically, however, 
no such distinction can be maintained. One may often see that a 
child becomes affected with glandular swellings in the neck in conse- 
quence of an eczema of the head, and that these glands, which origi- 
nally were simply hypertrophic, nevertheless, after the eczema has 
long been cured, pass over into suppuration, and become tubercu- 
lous. It is scarcely possible to separate the scrofulous from the tu- 
berculous glands, for the transition of the former into the latter occurs 
gradually, and does not manifest itself by any precise symptoms. 

Pathological Anatomy. — Numerous extirpations of hypertrophied 
glands, and multiplied post-mortem appearances, have shown that 
simply hypertrophied and tuberculous infiltrated glands may occur in 
the same person. 

In the simply hypertrophied glands there is but a slight alteration 
of structure. The longer they have existed, all the firmer and denser 
becomes the substance. The superficial surface, in most instances, is 
very vascular ; when cut into and compressed, a turbid fluid may be 
squeezed out, which, under the microscope, exhibits the characteristic 
glandular element, numerous granules, a few cells, and some connec- 
tive-tissue fibres. Occasionally smaller and larger cavities, with clear 
contents, occur scattered throughout the parenchyma of the gland. 

The tuberculous glands are always at the same time enlarged, 
and, on section, display either small hyaline, gray miliary tubercles, 
or large yellow tubercles, and aggregations of tubercles. In the se- 
verest form of the evil almost the entire glandular parenchyma -v^dU 
disappear, and be supplanted by a tuberculous mass. Suppuration is 
the usual termination of tuberculous glands; calcification seems to 



552 DISEASES OF CHILDREX. 

occur but very rarely in cliildi'en. As tlie softening ^^rogresses, tlie 
parenchyma and adjacent cellular tissue become inflamed, abscesses 
form, and finally tbe well-known, slowly-iiealing fistulous tracts and 
undermining ulcers result. 

Symptoms. — Tuberculous glands are most frequently situated on 
the neck, and a single gland alone hardly ever becomes affected ; 
large convolutions, as a rule, may be felt on both sides of the neck, 
under the chin, and behind and beneath the ear. When the glands 
become enlarged very slowly and without any pain, they usually re- 
main tolerably movable ; in the contrary case, and particularly^ when 
they pass over into suppuration, they become tense and immovable. 
A lively pain, increased on pressure, then comes on in all cases, the 
integument constantly grows redder and thinner, finally breaks, and 
a -flocculent, thin pus escapes, with which large tubercular granules 
are occasionally ex23elled. Generally several glands break open at 
one time, or soon after each other, at different places, and the suppura- 
tion is always extremely tedious. Very peculiar ulcers, ^vith callous, 
extuberating edges and lardaceous bases, now form, from which irregu- 
lar portions of the gland protrude. 

Finally, after several months, the callous edges soften, the ulcers 
become clean and heal up, but not without the formation of disfigming 
cicatrices. It is a remarkable fact that the general state of the sys- 
tem does not suffer here at all ; the cliildren look blooming, and thrive 
excellently well, provided the tuberculosis remains confined to the 
glands, and does not simultaneously attack the lungs, or some other 
vital organ. The course, aside from the disfiguring cicatrices, is, in 
the majority of cases, favorable ; and usually, when the ulcers have 
once completely healed up, no new swellings and suppurations ensue. 

As regards the comphcations, according to JLeherfs famous re- 
searches, scrofulous ophthalmia precedes or becomes superadded in 
seven-sixteenths of all the patients, two-fifths of the cases become 
comphcated with diseases of the bones, one-fourth with cutaneous 
affections, one-fourth likewise with diseases of the joints, and one-sixth 
with superficial ulcers and abscesses. According to the observations 
of the same author, tuberculosis of the glands is very rare between 
the first and fifth year of life, i. e., one-twelfth of its cases, more fre- 
quent between the fifth and tenth year, rate one-fifth; most fre- 
quent between the tenth and fifteenth year, viz., almost one-third 
of all its cases. From the fifteenth to the twentieth the frequency is 
still considerable, i. e., two-sevenths. From that time on, the disease 
becomes more rare ; for, after that age, tuberculosis more frequently 
attacks the lungs than the hnnphatic glands. 

Tuberculosis of the l^miphatic glands is of itself devoid of danger, 



GEXEEAL DISEASES OF THE SECRETIONS. 553 

but very generally tuberculosis of the lungs comes on after puberty, 
and prognostic ally, therefore, this danger must always be kejat in 
"view. 

Treatment. — In the simple and inflammatory hypertrophy of the 
glands, the cause is, above all, to be taken into consideration. The 
glands never grow smaller so long as "the scrofulous affection of the 
skin or mucous membrane, that has produced it, still continues. Not 
till after these have been cured, and the glandular hypertrophy does 
not disappear, may the effort be made to remove it by the local ap- 
phcation of tincture of iodine twice or thrice weekly. Simple swell- 
ing of the glands disappears under such a use of iodine continued for 
some time, but tuberculous very quickly thereby become inflamed 
and come to suppmation more quickly. Still, this last jDrocess need not 
be looked upon as an unfavorable occurrence, because the tuberculous 
masses cannot be absorbed, and are really eliminated from the system 
in this manner. 

The tuberculous softening at times goes on surprisingly slowly ; 
it scarcely ever, however, fails to take place, for calcification rarely 
occurs in childhood. All cutaneous irritants seem to accelerate it, and 
it is therefore rational to employ them. Here belong all the salves 
and plasters which make the skin red and inflamed, and a large number 
of which are current as popular remedies. 

The ulcers that have already broken are to be treated according to 
the generally-adopted rules of surgery. When the healing is pro- 
tracted for too long a time, a marked progress may be perceived from 
the use of red-precipitate ointment. Against simple induration, iodine 
will always prove a sovereign remedy. The greatest caution, how""- 
ever, must be exercised, in its internal use, for the always-to-be-sus- 
pected pulmonary tuberculosis occasionally makes visible progress 
thereby. Mineral waters containing iodine and bromine are best 
adapted for long use. Hypertrophied glands may soon be reduced 
in size by the continuous local use of tincture of iodine ; it mil, how- 
ever, very seldom be possible to remove them altogether. 

Extirpation of glands can only come into consideration when the 
inflammatory phenomena have long ago disappeared, and only a 
few glands have remained hypertrophied. In the contrary case, the 
wound of the operation, instead of healing up, may be expected to 
assume the character of a glandular ulcer, with the well-known callous 
edges. 

(d.) Bones^ Inflammation of the Periosteum [Periostitis Scrofic- 
losa). — Inflammation of the periosteum is not infi-equently the mani- 
festation of scrofula or local phenomena of other remote affections, and 
occurs either as an acute inflammation or has a chronic insidious and 



554: DISEASES OF CHILDREN. 

sometimes a very destructive termination. In rare instances a trans- 
formation of the primitive ckronic into an acute periostitis may be ob- 
served. 

The disease extends over a larger or smaller part of the bone ; 
sometimes it attacks the periosteum of the bone in its entire circum- 
ference. Its site is generally on the long tubular bones of the ex- 
tremities (tibia, femur, and humerus) and other compact bones ; 
spongy bones are seldom aifected. 

The pathological character of acute periostitis, which occurs as 
often as the chronic, is distinguished by an acute injection of the 
periosteum, mostly in the form of a uniform redness and by a swollen, 
flocculent, and spongy appearance ; later on, the periosteum is bathed in 
a muculent, tenacious, shreddy fluid exudation, and can be easily peeled 
ofP. In the insidiously-appearing periostitis, the hypergemia is less in- 
tense, more in the form of a striped or spotted redness ; the periosteum 
changes to a lardaceous, grapsh-red, or grayish-white mass, which is 
less easy to pull off from the bone and adjacent soft parts. When the 
disease has existed for some time, the latter as well as the j^eriosteum 
will frequently contain small spiculfe or lamellae of newly-formed osseous 
substance ; these are always apt to form whenever the periostitis is of 
some duration. 

The additional alterations which the inflamed periosteum undergoes 
are as follows : 

Complete resolution and retrogression to normal texture are extreme- 
ly rare ; a permanent hypertrophy and increase in bulk, w^ith organiza- 
tion of the inflammatory product into sohd tissue, occur somewhat 
more frequently, though on the whole hkewise rarely ; the termination 
in suppuration or sanies is predominantly frequent. In the latter 
processes pus forms in the inflamed periosteum as well as in the ad- 
jacent soft parts, wliich, uniting with the purulent collections in the 
bone, may form one large purulent reservoir. If the pus breaks out- 
wardly and the periostitis was limited to a small, circumscribed spot, 
healing and cicatrization may- indeed ensue, still these are very rare oc- 
currences ; the periosteum, as a rule, is undermined to a great extent, 
and separated from the bone ; the latter is thus deprived of its nutri- 
tive conditions necessary for its existence, and the next effect is necrosis. 
In other cases, and when the influence of the scrofulosis continues, the 
suppuration assumes the character of ichorous Hquefaction, which also 
extends to the subjacent bone, and induces in it the same process — 
caries (S. caries and necrosis). 

Scrofulous periostitis less frequently indicates tuberculosis than 
scrofulous ostitis, for tuberculous masses often appear as the inflam- 
matory product of the last. The symptoms of scrofulous periostitis 



GENERAL DISEASES OF THE SECRETIONS. 555 

are in general those of ordinary periostitis, and differ according as to 
whether the course is acute or chronic. In most cases there is at first 
a local, not distinctly-defined pain, diffused along the length of the 
bone ; it has a peculiar dull character, and is aggravated on pressure. 
Soon the pain, which at the commencement was only transient, becomes 
more constant and severe, particularly in bad states of the weather, 
frequently also at night. The affhcted Hmb swells faster or slower ac- 
cording to the character of the inflammation, the skin becomes tensely 
stretched, and can no longer be raised in folds ; in the first stages the 
tumefaction is hard and dense ; when suppuration ensues, one or more 
soft places will be found, then distinct fluctuation, and finally the 
abscess breaks, after the cutis has become bluish red in color and the 
epidermis elevated. Spongy granulations, which bleed at the slight- 
est touch, exuberate from the openings, which often rapidly become 
enlarged. The pus that escapes differs in character according to the 
depth the processes run (caries or necrosis). 

The general condition of the system, in the chronic course, is often 
but little affected, if it is not disturbed at the same time by other re- 
mote scrofulous diseases ; on the other hand, in the acute as well as 
in suppurative stages it is always attacked by febrile phenomena, 
which may attain to hectic fever in the case of extensive profuse sup- 
puration and weakness of the individual, which are frequently present. 
It terminates with the destruction of the patient. 

According to the described symptomatology, it will not be espe- 
cially difficult to form the diagnosis. 

The prognosis must be put down as unfavorable, on account of the 
caries or necrosis which so frequently follows. The periostitis, even 
before these processes have distinctly developed themselves, may 
endanger the life of the patient by profuse suppuration. 

Therapeutics. — The treatment, at the commencement, should be 
mth resolvents, although these will bring about the desired effect in 
the smallest number of cases only ; in addition to these, pain-assuaging 
remedies (internally and externally) must be employed, combined with 
absolute rest of the afflicted Hmb. Cataplasms, as a rule, relieve the 
pain very quickly, and for a long time, especially in commencing sup- 
puration; but, as soon as that is clearly ascertained, the abscess should 
be punctiu-ed, for, if it is delayed, the rapid accumulation of matter 
will extensively separate the periosteum from the bone, and large por- 
tions of it will be destroyed in most instances. 

Inflammation of the Medulla of the Bones ( Osteomyelitis — En- 
dostitis). — Inflammation within the medullary canal of the tubular 
bones occurs tolerably frequently in scrofulous persons. The anatomo- 
pathological conditions of this affection are : hypersemia, mtli dark-red 



556 DISEASES OF CHILDREN. 

discoloration of the marrow, conjointly mtli wliicli small extravasa- 
tions of blood now and then also occur, followed by suppuration, 
at first at small scattered places, which spread more and more, while 
the hypersemia subsides. The medulla retains a dirty, brownish-red 
color, and liquefies ; the bony walls are seen either discolored, per- 
vaded by granulations and ichor, undergoing absorption, and be- 
coming carious, or, when the suppuration of the medulla increases 
rapidly, they are seen to lose their supply of blood, and to be attacked 
by necrosis (caries and necrosis centralis). After a while the affection 
may attack the bone in its whole thickness, implicate the periosteum, 
and induce the same processes, which will be described in detail in 
the inflammation of the osseous structure and its terminations. The 
symptomatology and therapeutics are also almost identical with those 
of that affection. 

That form of inflammation of the marrow appearing in scrofulous 
subjects, in which the contents of the medullary spaces, and the can- 
cellous structure of tubular bones, especially those of the hand and 
foot, appear inflamed, is of more frequent occurrence than the above ; 
inflammation of the periosteum is always present with it. The pro- 
cess, which in its subsequent stages is known as osteoporosis, 
osteospongiosis, spina ventosa^ is of such a character in the first 
periods that all the osseous cancelH, and the medullary cavities, are 
found filled with dark-red, bloody fluid, rich in cells, sometimes 
even with purulent degenerated marrow, while the periosteum is 
seen hyperaemic and swollen. At a further stage of the evil, puru- 
lent dissolution and absorption of the osseous substance take place 
within the bone through the inflammatory action, by which the can- 
celli attain to abnormally large size, while, externally, irregularly, thin 
bony lamellse form, from the similarly-inflamed periosteum, and, in 
part, are again destroyed by the process of absorption which goes on 
from within. In this manner the bone may increase in bulk enor- 
mously, while its substance has, nevertheless, become diminished, for 
its internal part consists of very large, coarse meshes, large cavities, 
or irregular cells, very much as if the bone has been strongly inflated 
(therefore, also, the name spina ventosa). In the developed state of 
the afi'ection, it is impossible to distinguish the cancellous structure 
from the medullary cavities. 

The afi'ection frequently occurs, in scrofulous children, on the hands 
and feet, and generally on the metacarpal and metatarsal bones, or 
the phalanges, which often become expanded and misshaped, and pre- 
sent bulbous or globular swellings (similar to the enchondroma on 
the fingers, which the process under consideration also resembles in this 
respect : that in it, as a rule, the joints remain free or unaffected). 



GENEKAL DISEASES OF THE SECRETIONS. 557 

The process often does not attain to suppuration, but, wlien it does, 
numerous fistulous openings will form ; most of them, however, remain 
small. 

Therapeutics. — By the use of proper remedies, directed against the 
fundamental disease, in addition, by bathing the afflicted hmb (either 
Avitli tepid or alkalescent water), and by a compressive bandage, ap- 
phed for a long time, a cure may not infrequently be performed with 
but shght deformity. 

Inflammation of the Bony Structure {Ostitis Scrofulosa). — In- 
flammation of the osseous tissue frequently occurs in scrofulous chil- 
dren, and has its site cliiefly in the spongy bone-tissues (in the irregu- 
lar and short bones of the extremities, in the epiphyses of the long 
bones, the vertebrae, etc.) ; still, it also occurs in the flat, compact, and 
tubular bones ; in fact, no bone of the skeleton is excepted. 

An inflammatory nucleus forms at some part of the bony structure, 
which quickly gains ground, or several originate, and then become con- 
fluent, under more or less marked hypersemia, which may attain to actual 
extravasations of blood. The cancelli of the bone are superabundantly 
filled with an oleagino-gelatinous fluid, which is soon supplanted by 
granulations, displaying a profuse quantity of cellular structure ; the 
cancelli of the bony-tissue become larger as the granulations produce 
an absorption of the osseous tissue (osteoporosis). The bone itself, 
at the inflamed place, appears larger in bulk, although its structure 
has not increased, but, on the contrary, become diminished. This 
condition becomes particularly apparent when the inflammation is 
situated near the superficial surface of the bone. Abscesses are also 
often seen to form in the adjacent soft parts, even when the inflam- 
mation is situated in the depth of the bone, and does not involve its 
superficial surface. 

In scrofulous subjects the tuberculous inflammation, which attacks 
especially the spong}^ bones and epiphyses, is the form which most 
frequently occurs. Accompanied by hyperaemia, one or several nuclei, 
of a globular form, or a uniform infiltration of the osseous substance, 
with a semi-transparent, yellowish-gray, gelatiniform exudation, takes 
place. When there are only a few scattered nuclei, some of them 
\^dU be surrounded by a sort of envelope, which likewise emvi'aps the 
exudation, but it disappears in the progress of the lesion. Softening 
soon takes place, the several aggregations turn to a yellowish color, 
a crumbling, cheesy matter is seen in the thick, pultaceous fluid, and, 
when the process goes on faster, and is more extensive, small frag- 
ments of bone will not infrequently be found. By this process cavi- 
ties form in the bone, which, by constant extension and approxima- 



558 DISEASES OF CHILDREN. 

tion, -syill finally unite into considerable-sized caverns ; the bone be- 
comes rotten, and crumbles down, as it were, within itself. In the first 
stage, recovery may take place by the fluid contents of the nodes becom- 
ing absorbed, and these undergoing calcification, while the bony tissue 
near them becomes condensed ; but the breaking of the abscess, and 
evacuation of the tuberculous matter, with a continuation of the pro- 
cess as tuberculous caries, which then passes through its various me- 
tamorphoses, are of more frequent occurrence (S. caries). 

Tuberculous infiltration attacks either a whole bone or a part of it 
— a vertebra, for example — in this manner : a bone is pervaded by the 
yellowish-gray inflammatory product, and a number of yellow streaks 
and spots soon appear, which rapidly become enlarged, coalesce, and 
consist of purulent fluid, intermixed with crumbling, granules, which 
quickly assume the character of a puriform ichor or sanies. Under 
its influence the bony tissue soon breaks down into small or large 
particles, which are sometimes found in the ichorous fluid that is dis- 
charged. If the process goes on still further, it may next also in- 
volve the periosteum, destroy it, and cause death and exfoliation of 
the bone. In other, rarer instances the disease becomes arrested after 
the exfoliation of the infiltrated parts, and a recovery takes place by 
the cancelli becoming fiUed up with granulations which spring up from 
the still healthy adjacent part of the bone, or from the periosteum 
and its vicinity. The terminations of inflammation of the bony sub- 
stance, after it has existed as such for a longer or shorter period, are : 

(1.) Resolution. Complete resolution is an exceedingly rare oc- 
currence in scrofulous persons, and is only observed in inflammations 
implicating small portions of a bone. 

(2.) Siqopuration, with subsequent healing ^vithout transition into 
caries. The transition into suppuration occurs tolerably often; a 
cure, however, is rarely effected after the breaking and evacuation 
of the abscess have taken place ; in most cases purulent infiltra- 
tion and protracted caries then follow. In this termination the can- 
celli are distended, enlarged, and full of pus, and, as the bony substance 
breaks down, larger or smaller cavities form — a process which may 
go so far that finally but one cavity is to be found, extending through- 
out the whole bone, having only a thin osseous shell, which constantly 
grows still thinner, covered by periosteum — abscess of the bone. If 
the matter has tunneUed its way into the soft parts, it may then either 
break through, especially if abscesses preceded by inflammation have 
already formed in these, either in a straight direction, corresponding 
to the site of the affection, or it may travel on for a distance between 
them, and appear at a greater or lesser distance from the original 



GENERAL DISEASES OF THE SECRETIONS. 559 

place. The pus is yellow or yellowish white, devoid of any bad odor, 
in most instances somewhat thin, and has no corroding properties 
(it is said to contain a larger quantity of phosphate of lime — Y-|-g- to 
YYo — than pus formed in soft parts — sio)' The pus continues to be 
discharged for some time, and when, in favorable instances, it ceases, 
the orifice will close, and the cavity becomes filled with granulation, 
in which, in the course of time, ossification takes place. 

(3.) Caries. 

(4.) Necrosis. 

Both these terminations of inflammation present such noteworthy 
peculiarities that they have to be considered separately. The symp- 
toms of ostitis vary according to its site and extent, and as to 
whether the soft parts are implicated in the inflammatory process or 
not. Pains are never absent. Sometimes they are stationary, and 
then again migTatory and radiating. 

The tumefaction of the afi"ected parts also varies, and, as a rule, it 
is difficult to decide how much is due to the oedema of the soft parts, 
and how much to the hypertrophy of the bone and periosteum. The 
integument is mostly very sensitive and inflamed, particularly when 
abscesses threaten to break through. Not infrequently such abscesses 
originate in the soft parts, without any connection with the afi'ection 
of the bone, break open, cicatrize, and leave behind irregular, de- 
pressed eschars. 

In chronic ostitis the general condition of the system may be but 
little perturbed, and only participates when suppuration sets in 
through febrile phenomena, etc. ; in ostitis that occurs with acute 
fever, emaciation, debility, disturbance of the sleep, loss of appetite, 
and diarrhoea, are but seldom absent. 

Treatment. — When the course is slow and the pains moderate, 
iodine ointment and mercurial plaster (when the general condition al- 
lows the use of the latter remedy) may be employed for the purpose of 
bringing about resolution, or vesicants and setons, as derivative reme- 
dies ; in the acute condition, in consequence of the very severe pains 
that are present in the great majority of cases, pain-assuaging reme- 
dies will have to be resorted to along with absolute rest of the limb, 
as resolution is altogether out of the question : cataplasms, often re- 
peated ; when the exacerbations are intense, ice and cold irrigations 
are remedies which are better tolerated than is generally believed. 

When the abscesses have broken externally, the treatment must be 
conducted with a view to facilitating the discharge of the matter : injec- 
tions into the fistulous passages and cavities are often necessary. 

ULCERATIOI^r OF THE BoNE {CaHes^ Ulcer atio Ossis). — In scrofu- 
lous persons, caries most frequently develops itself from a primary 



560 DISEASES OF CHILDREN. 

ostitis in one or several bones, and is predominantly frequent in 
the spongy bones ; it is produced less often by periostitis as a re- 
sult of the ulceration of the periosteum having been propagated upon 
the bone. Caries, therefore, almost always progresses from the centre 
toward the periphery, from within outward (caries centralis, c. pro- 
funda), or, in the rarer cases, from without inward, from the periphery 
toward the centre (caries peripherica, c. superficialis). Sometimes it 
is circumscribed, and thus presents the peculiar abscess of the bone ; 
sometimes diffused ; sometimes, again, involving only solitary parts of 
the bone, and then, again, its entire circumference (caries partialis and 
totalis). 

Caries develops itself, after the above-mentioned inflammatory pro- 
cesses, in this manner : the granulations secrete a reddish-bro^vn fluid, 
which, in common mth the degenerated fat-cells and the sparsely-pres- 
ent pus-corpuscles, represent the ichor with which the cancelli become 
filled ; then gradual atrophy of the osseous trabeculas takes place, by 
which the bone so affected becomes soft and compressible, and finally 
disappears altogether by the destruction which attacks layer after 
layer. 

Frequently, the bony substance is not destroyed by the gradual 
atrophy and degeneration alone, but also by necrosis, as normal parts 
of the bone lying next to the carious or already-ulcerated parts are 
deprived of their nutrition, die of themselves, and form larger or 
smaller sequestras (caries necrotica). 

The ulceration of the bone also spreads upon the surrounding 
parts, which, as a rule, have already been affected by preceding in- 
flammation. The periosteum undergoes destruction through the pu- 
rulent infiltration of the soft parts ; the cellular tissue, particularly 
where the periosteum is destroyed, is attacked by ulceration ; in it 
large and small abscesses and sinuses form, and finally one or more 
break outwardly, and the carious ichor escapes. In the soft parts, 
particularly those in the vicinity of the periosteum, osteophyte form.a- 
tions are frequently found. 

The discharge, in most instances, is thin, of an insipid, nauseous 
odor (resembling putrid flesh), mixed with particles of bone, or, in 
tuberculous caries, with cheesy granules and flakes, and likewise mth 
small bits of bone. Soft fungous granulations exuberate around the 
mouth of the sinus, frequently blocking up its entrance, and bleed at 
the slightest touch. The fistulous tracts, as a rule, run in a straight 
or oblique direction to the affected part of the bone ; sometimes they 
also make many twists and curves, for the discharge does not reach 
the upper surface of the bone in a straight but in a roundabout way. 
The affected part of the bone will be reached by the probe with more 



GENERAL DISEASES OF THE SECRETIONS. 561 

or less difficulty, according to tlie course of the sinus, and is felt to be 
rough and uneven, as if worm-eaten, and easily impressible. (Probes, 
lead-plaster, etc., when brought in contact with the discharge, be- 
come discolored by the combinations of sulphur it contains.) 

The general state of the system suffers but little in caries, in case 
small bones at a distance from the centre of the body are attacked. 
In other cases, for example, caries of the vertebrae (s. spondylarthrocace), 
it will be deranged in the highest degree. In the great majority of 
cases recovery will not take place until the cachexia, which lies at the 
root of the evil, is eradicated, and even then the caries sometimes goes 
on until the affected bone is destroyed, and, in fact, involves yet other 
adjacent parts. If recovery is to take place, suppuration and atrophy 
of the bone have to cease, the granulations then become firmer, more 
consistent, and richer in fibrin ; from these, as well as from adjacent 
structures, preferably from the hypertrophied periosteum, ossification 
next ensues, by which the loss of substance is remedied. 

The diagnosis, as well as the prognosis, is in greater part infer- 
able from what has already been said. If it is not possible to reach the 
carious bone even with the probe, owing to the complicated course of 
the sinuses, the diagnosis can be established with perfect safety from 
the quaHty of the pus, the appearances of the orifices of the sinuses, 
the whole manner of origin, in unison with the locality of the nature of 
the bony part {spongioiis hone), and the nature of the general affection. 

Treatment of Caries. — The local treatment consists of bandag-es 
and moist compresses, or moist pledgets of charpie, which have to be 
zealously renewed, while the affected limb is kept in such a position 
as not to hinder the escape of the pus. Haemorrhages from the spongy 
granulations are best controlled by touching them with lunar caustic, 
or some mild astringent, and a graduated compress. Topical baths 
are worthy of recommendation, and, whenever the locality permits of 
their application (hand, foot, etc.), should be employed. Besides 
warm- water baths, alkaline and sulphurous baths, for the sake of 
cleanliness, should be frequently ordered, and, when very severe pains 
are present, they may be rendered narcotic by the addition of lauda- 
num, etc. 

General baths are likewise very beneficial, still they should not 
be employed where there is any great degree of debility, nor should 
any danger be combined with the bathing (for example, in caries of 
the vertebrae). Abscesses which are in direct connection with the 
bone or periosteum, and fluctuate distinctly, should be opened ; con- 
gestive abscesses as late and as seldom as possible. 

Consistent operative procedures may be resorted to , in caries, hav- 
36 



562 DISEASES OF CHILDREN. 

ing for their object the exsection of smaller or larger portions of bone, 
and even amputations and exarticulations. But the indications for 
these depend so much upon the circumstances of the individual cases, 
in reference to their local affections and general state of the system, 
compared with the benefit that can be derived from an operative un- 
dertaking, that no general rules can be laid down. 

Necrosis, Gangrexe (Death of a Part of a Bone). — Necrosis 
of the bones may be brought about in scrofulous subjects by inflam- 
mation of the periosteum, of the bone-substance, or of the medulla, in 
which the bones, through the uprooting of the periosteum, or of the 
endosteura, by impermeability of its vessels, as an effect of obstruc- 
tion or pressure by exudation, having its usual nutritive conditions de- 
stroyed, must die. In this manner all causes and incentives of caries 
may also induce necrosis. 

Necrosis usually attacks only one part of a bone, and generally 
either the external bone lamellae as necrosis externa (n. superficialis), 
or the inner lamellae of a medullary canal, or a portion of the spongy 
bone-substance in the depth, as necrosis interna (n. centralis) ; it may 
also involve the bone in its entire thickness, even in its complete to- 
tahty (necrosis totalis). 

Necrosis, it is true, occurs in scrofulous subjects on all the bones, 
still certain bones are predominantly often affected, especially the 
diaphyses of long tubular bones (tibia, femur, humerus, radius, and 
ulna) ; next to these the flat bones of the skull. In the spongy bones 
it is observed in common with caries ; aside from that, these are less 
frequently attacked by necrosis. The process of necrosis presents 
somewhat different features according to its site. 

(a.) In central necrosis (necrosis interna) the separated piece of 
bone that has been deprived of its nutrition — the sequestrum — lies in 
a cavity lined by granulations — sequestrum capsule — the walls of this 
cavity consist of old and new bone, which may just as well be formed 
in "the medullary canal as upon the upper surface of the bone by the 
inflammatory process which is present here and there ; the osseous 
substance subsequently becomes compact, and the bone on that ac- 
count appears thicker and larger in bulk. A variable number of 
openings, lined by granulations, form in the sequestrum capsule, 
which are continued into the ca\dty, and terminate externally — 
cloacae. 

The orifices on the bone are round, oval, of various sizes, and 
surrounded externally by walls of granulations ; pus escapes from 
them so long as the sequestrum is enclosed in the capsule, and, al- 
though they occasionally heal up temporarily, still, as a rule, they al- 
ways break open again. 



GENERAL DISEASES OF THE SECRETIONS. 563 

When the sequestrum is removed the cavity fills up with granula- 
tions, and immediately thereafter with compact bone-tissue — provided 
the general system has not been very much reduced — the sinuses, 
in most cases, close up with contractions of the soft parts, which re- 
main visible for life. 

(b.) In superficial necrosis — the result of periostitis — the sequestrum 
is not, as a rule, entirely enclosed in a capsule. This form has a more 
favorable chance of being cured, as the sequestrum is more readily ex- 
pelled or may easily be removed ; the sheath in which it was confined 
becomes filled up with granulations, and the opening closes up with 
a cicatrix contracted do^vn to the bone. 

(c.) In necrosis totalis a complete capsule forms, although rarely, by 
the peripheral formation of new bone on the border of the sequestrum, 
the capsule is complete, has a large cloaca, and the soft parts are 
mostly intersected by sinuses of considerable size and width. If the 
bone has been cast ofi", the large cloaca will be filled up with granu- 
lations continuous from the sequestral surfaces, the periosteum and the 
rest of the soft parts, in which bone-substance forms, in a longer or 
shorter time. 

(d.) Necrosis of the entire bone occasionally occurs, in scrofulous 
subjects, on the hand and foot, and is always the result of intense 
periostitis and ostitis. The sequestrum, which consists of the entire 
bone, exhibits therefore the most traces of inflammation, and is 
sometimes carious in a high degree, osteoporotic, and lies in a wide 
cavity filled with ichor and pus. After the sequestrum is removed, 
the cavity may become filled with granulations, and new circlets of 
bone may be formed from the hypertrophied periosteum and soft 
parts. 

In regard to the symptomatology of necrosis, every thing is essen- 
tially applicable that has been said in the consideration of periostitis 
and ostitis. When the abscess has broken or been opened, dead 
bone, if the process has already attained to necrosis, will be reached 
through the opening. In most instances this necrosed bone, when 
struck, will emit a dull, dead sound, and is felt to be smooth and 
firm ; still, in total necrosis of the spongy bones, it is also very rough, 
uneven, and fragile. It is very difficult, in such cases, to distinguish 
between caries and necrosis, especially since the discharge from the 
sequestrum capsule may also be ichorous. 

As regards the prognosis, it is most favorable in superficial necro- 
sis ; doubtful when the aff'ection is located deeper, and extends over a 
large portion of the bone ; and unfavorable when the entire thickness 
of the bone has been involved. In strumous persons, the intensity 



564 DISEASES OF CHILDREN. 

and extent of the inflammation, and the subsequent suppuration, tend 
to endanger the accession of hectic fever. The fact is of great 
importance, that such cases, as a rule, can only be relieved by an op- 
eration, which of itself is not dangerous. 

The treatment, besides the subjugation of the cachexia, which Hes 
at the bottom of the malady, should especially be directed to the ex- 
pulsion or artificial removal of the sequestrum as quickly as possible. 
In superficial necrosis this indication is readily enough carried out ; it 
is only necessary to open the abscess that is forming, or to dilate the 
already-existing opening, and to extricate the sequestrum, provided 
it is completely detached from the bone; but where this does not 
happen to be the case, then we should patiently wait, and use only 
simple dressings and bandages, in jDreference to all serious undertak- 
ings, such as cauterizations with the actual and other cauteries, ex- 
section, etc. In encapsulated necrosis (the central, and frequently the 
total), there is always a mechanical impediment which prevents, or at 
least retards for a long time, the expulsion of the sequestrum, and it 
has to be removed by mechanical means, as too long delay tends to 
induce unfavorable accidents. The means of extracting the seques- 
trum from the capsule that surroimds it consists in enlarging the 
orifice sufficiently by the aid of the trephine, osteotome, small saw, or 
chisel, after which the dead bone is pulled out with the bone-forceps, 
etc. The filUng up of the cavity with granulations, the cicatrization, 
and the rest of the recovery, are patiently waited for ; a simple com- 
pressive bandage is employed, and the general system is unproved as 
much as possible by appropriate remedies. 

Ikflaioiatiois" of the Veetebrje IX Scrofulous Subjects. — 
Tuberculous Destructive Inflammation of the Vertehrce^ Tuberculosis 
of the Yertebrm, Spondylarthrocacef" 3Ialum Potii^ Kyphosis Par- 
alytica. — This evil, of such frequent occurrence in scrofulous children, 
originates generally as a local manifestation of scrofula without any de- 
monstrable cause ; in some instances, however, it is produced in scrof- 
ulous subjects by traumatic influences, as falls, blows, etc. The nature 
of the disease is an inflammation of one or more bodies of the verte- 
brae, having the tuberculous character and the very marked tendency 
to deliquescence and ulcerative destruction of the bone. The affec- 
tion, as a rule, appears in the form of ulcerated tuberculosis — accord- 
ing to the above-described precedents — less frequently as decapsulated 
tuberculous nodules, generally in the centre or near the centre of the 
body of a vertebra. Those cases in which the vertebral laminae, trans- 

* The name spondylarthrocace, most frequently employed for this disease, is not 
well chosen, as the vertebral joints participate only secondarily, and may even remain 
perfectly free. 



GENERAL DISEASES OF THE SECRETIONS. 565 

verse or oblique processes, are primarily attacked, are extremely rare, 
and tlie affections of the articulating surfaces are still rarer. The in- 
tervertebral cartilages, it is true, undergo destruction, but only sec- 
ondarily, when the disease encroaches upon them, or Avhen the verte- 
bral bodies sink together with resulting curvature. This happens 
after the bodies of the vertebras have become entirely, or in greater 
part, infiltrated, when cavities have formed by the dissolution of the 
tuberculous masses, so that the vertebras are no longer able to support 
the parts resting upon them. Curvature then results, in most cases 
backward (kyphosis), but, as a rule, is combined with more or less 
marked lateral distortion (scoliosis, kyphosis scoliotica) ; it mostly 
originates gradually, seldom rapidly ; in very rapid softening, the result 
of an injury to the diseased place, etc., it is very sudden, and neces- 
sarily attended by alterations within the spinal canal, hyperaemia, 
inflammation, and softening of the spinal meninges, and of the cord, 
and compression of this organ, without, however, inducing in all cases 
serious phenomena ; indeed, these are very slight in some. In curva- 
ture of the spinal column the sympathetic nerve experiences a violent 
strain ; still, nothing positive is known in regard to the symptoms 
thus jDroduced. 

The affected vertebree generate and support, in their immediate 
vicinity, an inflammatory process, which soon terminates by profuse 
suppuration. Purulent accumulations form ; most of them extend far 
down as psoas or depending abscesses on the anterior surface of the 
spinal column to below the inguinal region, or into the pelvis. Pos- 
teriorly also — on the dorsum — such abscesses make their appearance, 
sometimes attaining to enormous sizes. These abscesses break but 
very rarely into the spinal canal. They contain thin pus or ichor, 
mixed with decomposed or degenerated tuberculous masses, as also 
fragments of bone and ligamentous shreds ; in most instances the mat- 
ter has a very pungent, nauseating odor, colors the probe black, etc. 
(S. caries). 

In the contiguous parts, on the other hand, new formation of bone 
may be combined with destruction of the vertebrae, and the adjacent 
vertebrge, or the spaces between the laminae and the processes, may 
also frequently be found studded and filled out with dentated, irreg- 
ular bone-substance. Spontaneous dislocation of the vertebrae, mth 
the exception of the first two cervical, has very seldom been ob- 
served. 

The first signs of the disease relate to the spinal column, and con- 
sist in painful sensations emanating from it. Small children are rest- 
less, display symptoms of discomfort, cry when the back is touched, or 
when they are moved about quickly ; larger ones carefully avoid these, 



566 DISEASES OF CHILDREX. 

and sometimes complain of stationary, and sometimes again of fugitive 
pains at the diseased part, or in its neighborhood. 

An attentive examination of the back and spinal column should be 
instituted at the very commencement of the complaints of pain ; the 
back and spinal column should be felt and percussed all over, and the 
patient should be made to perform various bodily movements, for by 
this it will be more easy to define accurately the location of the pain. 
With these local symptoms there are also general phenomena present 
when the disease has once attained to any degree, for, loss of appetite, 
febrile excitement, sleeplessness, and diminution of the mental abili- 
ties, soon come on. 

At a further stage of the evil, important local derangements super- 
vene, namely, curvature of the spinal column backward and laterally, 
with which a deformity of the thorax progresses hand in hand, for the 
ribs stand off at a greater distance on the side of the convexity of the 
curvature than on the concave side. With this, modifications in the 
remote phenomena, according to the locality which the affection em- 
braces, manifest themselves. 

(1.) Spondylarthrocace thoracica begins in the manner described ; 
in addition, the patients complain of pains in the limbs, of a tickling 
sensation and formication in the calves and thighs, of pressure in the 
prsecordia and abdomen ; and not infrequently spasmodic affections in 
the parts mentioned also become superadded, quickly followed by con- 
stipation and difficulties in the nutrition. Every movement of the 
vertebras is studiously avoided ; the neck is dra^vn backward and short- 
ened as much as possible, so that the head seems to be stuck in deep- 
ly between the shoulders, the elbows are kept at the sides, and the 
hands rest on the thighs, the arms thereby forming a support to the 
upper part of the body. Psoas abscesses now form, paralyzations 
supervene, the general symptoms assume the character of hectic fever, 
not infrequently accompanied by Bright's degeneration of the kidney, 
and death ensues after a shorter or longer period. Still, the patient, 
if his strength has not been exhausted in too great a degree, may es- 
cape with his life (a not very frequent occurrence, it is true, in any 
stage of the local affection), of course, with an incurable curvature of 
the spinal column and thorax, along with paralyzations of the lower 
extremities, rectum, and bladder, which, as a rule, likewise defy all 
manner of treatment. 

(2.) Spondylarthrocace cervicales, angina Hippocratis. 

The further downward toward the thoracic spinal column the affec- 
tion is situated, all the more resemblance has the morbid picture to 
the one just sketched ; but, in addition, the phenomena on the part of 
the upper extremities, in the form of spasmodic or paralytic derange- 



GENERAL DISEASES OF THE SECRETIONS. 567 

ments, come into consideration ; the further upward the disease, all the 
more plainly the symptoms manifest themselves on the part of the 
digestive, vocal, and thoracic organs. (Hence the old denomination, 
angina Hippocratis.) In this form of the disease, swelling of the re- 
gion of the neck is observed, which sometimes attains to a considerable 
size, and the place of curvature may thus remain hidden by it from the 
examining finger. These swellings, in most instances, are tense, firm, 
and hard, and have hence acquired the name of " tumor albus nuchas " 
(analogous to the tumor albus of the joints). The greatest danger 
attends the disease when it is situated on the first and second cervical 
vertebras, because at this point it may readily lead to compression of 
the medulla oblongata,* and, owing to the importance of this organ, to 
a speedily fatal termination. The cause is, the great mobility of the 
joint connections, so soon as the ligamentum transversum atlantis 
is destroyed or materially injured. 

The movements of the head are painful ; they are avoided as much 
as possible,! and the nape and neck are kept stiff, or the movements 
of the head are aided by the hand. Generally the pains in the head 
are quite severe, and torture the patient very much, especially at night ; 
the difficulty of swallowing is frequently great, particularly when the 
disease has reached the stage of the formation of retropharyngeal ab- 
scesses, which, owing to the magnitude which they occasionally attain, 
may altogether prevent the patient from partaking of food or drink. 
This form of caries of the vertebrae, when the disease is to any degree 
intense, kills the patient either by the above-mentioned luxation of the 
upper cervical vertebra, or by its invading the meninges and brain, or 
through exhaustive discharges. Milder forms may improve and ter- 
minate in recovery — as a rule, with permanent or difficult-to-be-ini- 
proved deformity in the attitude of the head. (A kind of caput obsti- 
pum [torticollis] is indebted for its origin to this disease.) 

(3.) Spondylarthrocace lumbalis and sacralis. 

The site of this form, which is least frequently observed, is the lower 
section of the lumbar spinal column, the sacrum, and also a contiguous 
part of the coccyx in rarer instances. The real pains are not infre- 
quently preceded by unpleasant sensations in the thighs — in the form 
of ischias. The child lies in bed, on one side, with contracted thighs, is 
only able to rise with great difficulty, in which act it is obliged to support 
the region of the buttocks or hips with the hands (therein bearing some 

* Either by the spinal column curving at a very acute angle, or by the dislocation 
of one body of the vertebra from the other, thereby compressing or even tearing the 
medulla oblongata. 

f The child (as in a case at present under observation), when desirous of looking 
at an object at its side or behind, rotates the whole body toward it. — Tr. 



568 DISEASES OF CHILDREX. 

resemblance to coxitis). Purulent collections take place in the peMs 
and may escape throug'li tlie obturator foramen or into the rectum ; 
they seldom make their appearance in the inguinal region. Paralysis 
of the sphincters and bladder is rare, as the affection is located deep- 
ly, and the nerves which control these organs are found above the 
site of the disease. Life is jeopardized by the suppuration with its 
effects ; fatal meningitis or myelitis has also often been seen to ensue. 

Therapeutics. — The treatment, besides being directed to the sub- 
jugation of the cachexia, should be conducted with the view of pre- 
venting the spreading of the disease upon dehcate structures, the brain, 
meninges, and spinal cord. Every mechanical violence and all in- 
juries to the spinal column in particular, when the disease is confined to 
the upper section — for the reasons mentioned — are to be prevented 
with the utmost care. To accomplish this indication, a horizontal 
posture on the back, or, if this be impossible, the lateral decubitus 
upon a good upholstered mattress, should be prescribed for the patient 
so long as the morbid process is active, and he should be retained in 
that position, by mechanical apphances, under all circumstances. In 
order not to deprive the patients of the enjoyment of fresh air, they 
should be taken out upon the couch as often as possible. 

Besides the internal use and local apphcation of narcotics in the 
form of opium and ointments containing morphine, derivatives will 
have to be employed against the violent pains. Small blisters (upon 
which morphine is subsequently strewn) are very advantageous. The 
seton, however, will not infrequently be found to be more potent and 
none the less advantageous against the intense painfulness.* 

Depending abscesses, that are not voluminous, should be left un- 
opened as long as possible, since the disease, in most instances, makes 
more rapid progress after they are opened : if they have attained to 
great dimensions, are attended by excessive pains, and redness and in- 
flammation of the integument, indicating their approach to a speedy 
bursting, they may be opened and the pus allowed to escape. 

(e.) Joints, — Inflammations of the joints occur very frequently 
in scrofulous individuals as local manifestations of the general disease, 
without it being possible to demonstrate any other external cause, and 
are, as a rule, attended by other phenomena of scrofula in some remote 
part of the body. Pathologically, these inflammations differ in no essen- 
tial respect from others that have originated through injuries, rheu- 
matic influence, etc., but their phenomena derive a sufficiently peculiar 

* As in every other grave local disease attended by excessive pains, so also here, 
the hypodermic injection of morphine will be found to be an invaluable means of 
allaying the pains without running the danger of deranging the digestion by the in- 
ternal use of narcotics. — Tr. 



GENERAL DISEASES OF THE SECRETIOXS. 5^9 

character from the general disease which lies at the bottom of them. 
They begin and terminate either in an acute or chronic form, and take 
their origin either from the epijjhyses of the bones that enter into the 
formation of the joint, or from the membrane which lines the joint, the 
svno^dal (sometimes from both at the same time), and in this manner 
present in the former case the clinical picture of arthrocace, in the 
latter that of the fungous inflammation (tumor albus). 

I.— Artliroeace. 

The spongy joint-ends are attacked by inflammations which ter- 
minate in suppuration and caries, after the manner described in ostitis, 
etc. Suppurative degeneration (deliquescence) sets in, the cortex of 
the bone is involved in the carious process, and becomes perforated, ab- 
scesses form in the surrounding soft parts, while the pus or ichor, after 
the destruction of the cartilaginous part, tunnels a passage for itself 
toward the cavity of the joint, and quickly sets up in it a suppurative 
inflammation. After the cartilaginous coating of the joint has become 
disintegrated, and the synovial membrane and the ligamentous ap- 
paratus destroyed, the carious joint-ends of the bones will jDrotrude 
into the enlarged cavity, which is filled with ichor, by which exfolia- 
tion of the joint-ends of the bones not infrequently takes place. Dislo- 
cation of the ends of the bones is very apt to ensue, as the coaptating 
apparatus is attacked by the destructive process of the disease. 

The kind of inflammation just described attacks the hip-joint most 
frequently of all. 

II.— Fungus Articuli, 

In other instances the synovial membrane is found predominantly 
affected. In the incipient stages of the inflammation it is seen to be 
lax, injected, covered with small projections — granulations. It has a 
villous or varicose appearance ; by-and-by these granulations exuberate 
into shaggy, bulbous, inosculating excrescences, which project into 
the cavity of the joint ; the synovial membrane is thickened, infil- 
trated, and permeated by pus. The vicinity of the joint also partici- 
pates in the inflammation ; the cellular tissue and the ligaments of the 
joint, etc., are infiltrated with a gelatinous or lardaceous material, and 
pervaded everywhere by plethoric exuberations of connective tissue in 
the form of spongy masses. In consequence of the suppuration, the 
soft parts are not infrequently perforated by sinuses coursing in various 
directions, which often reach the immediate vicinity of a joint, in or- 
der, after perforating the capsule, either to terminate into it from 
without inward, or in a contrary manner. The subcutaneous cellular 
tissue is infiltrated, in most instances, with serum, and in a state of 



570 DISEASES OF CHILDREN. 

hypertrophy ; the integument is tense, white, and ghstening, so long 
as no opening has formed (a phenomenon which is often protracted for 
some time) ; hence the older denomination, tumor albus. The muscles 
around the joint generally become flabby, and atrophic, and undergo 
fatty degeneration. The cartilages of the joint either become coated 
by the fungous extuberations and degenerate into the same, or they 
quickly deliquesce through the abnormal contents of the cavity of the 
joint, and disintegrate to a pulpy, fatty mass. At a further stage of 
the disease, the bones are likewise invaded, and, in fact, in the ma- 
jority of these cases, become carious, so that in the end this form of 
inflammation may display the greatest similarities to the former. In 
both we not infrequently have the opportunity of observing in the 
vicinity of the joint, either in the osseous or in the soft parts, new- 
formed bone-substance, in the shape of irregular projections, small 
spiculas, and the like. 

In rarer instances the inflammation issues simultaneously from the 
bone and synovial membrane ; here, however, such abundant exuberat- 
ing granulations do not form so readily from the latter ; a very rapid 
suppuration in the cavity of the joint takes place instead. For the 
rest, the relative condition of the soft parts, etc., is the same. 

The fungous inflammation is principally observed on the knee- 
joint. 

Symptoms. — Scrofulous inflammation of the joints may appear as 
an acute, even very acute afi'ection, and terminate as such, or subse- 
quently pass over into the chronic state ; the beginning, however, 
may also be chronic, and remain so, or change to the acute form. 
In the latter case, when no febrile movements, due to other re- 
mote scrofulous manifestations, happen to exist, chills, alternating 
mth sensations of heat, loss of appetite, and great restlessness, super- 
vene, along with which symptoms, pains in the afi'ected joint and in its 
vicinity, not infrequently extended for a considerable distance, mani- 
fest themselves, either immediately or in a short time thereafter. At 
first, they are mostly intercurring, dull, and aggravated on pressure and 
motion ; soon, however, they become constant and intense, and some- 
times become so excessively severe, when an attempt is made to move 
the affected joint, that the patient will cry out loudly. This is also 
adequate to explain the marked tendency of the joint to assume a cer- 
tain position, and, indeed, such a one as will bring about the utmost 
possible equipoise, and cause as little tension as possible to the 
ligaments and muscles lying over the joint, because the traction thus 
obviated from the affected part serves best of all to make the pains 
bearable. Thus, for example, in coxitis the thigh is brought into a 
state of flexion, adducted and rotated inward to a moderate degree ; 



GENERAL DISEASES OF THE SECRETIONS. 571 

in the inflamed elbow-joint the forearm is placed midway between 
pronation and supination. Swelling of the joint, as a rule, soon 
becomes noticeable,* which is either limited to it, or extended for 
some distance beyond, and is of a round, spindle form, irregular in 
shape and size, and soft and doughy, or hard, tense, and firm, and 
only later on exhibits the signs of softening and fluctuation. 

The skin is sometimes reddened, tense, and permeated by small 
and large vessels (particularly venous inosculations), is increased in 
temperature ; or it may present no change of color, may be raised into 
smaller or larger folds, and be devoid of any perceptibly great amount 
of warmth. As the matter produced from the inflammatory product 
in the deeper structures and about the joints approaches the upper sur- 
face, the skin becomes red, not infrequently bluish, and the epidermis 
rises up like a blister. After a spontaneous or artificial opening has 
ensued, the pains subside for some time, as a rule, and the patient 
feels much relieved, but they invariably soon return, although not 
always in so severe a degree as before. In the further effects, the mor- 
bid picture assumes a difi'erent shape, according as to whether the dis- 
ease runs through an acute course or approaches more to a chronic 
one. In the first case, death, as a rule, ensues some time after the 
breaking of the abscess, under pygemic phenomena or consumptive 
fever ; in the second case, the malady may last for a long time, and 
death, at some future period, occur through exhaustion, or from a new 
accession of the inflammation, or the process may assume a favorable 
turn, and result in one of the remote terminations to be mentioned. 

The chronic form of the inflammation mostly begins with a mod- 
erate fever ; the pain, as a rule, is also slight at first, and is only 
aggravated by prolonged exercise or by severe pressure on the joint, 
or the patient suffers somewhat more from them in chilly and wet 
weather. In this manner the process may go on for a long period be- 
fore suppuration and bursting occur, by which the conditions undergo 
a change, according as to whether a difi'used inflammation sets in, or 
the disease retains its chronic character. If the former happens to be 
the case, all the symptoms of an acute inflammation of the joint with 
a rapid and severe course may then supervene. In addition to the 
unfavorable terminations described, the joint-inflammations, especially 
when they are treated in the proper manner, generally and locallj^, 
may present the following results : 

(1.) Recovery without any decided derangement of the function 
of the joint. This termination presupposes that the disease had not 
attained to a too serious degree, and that the cartilages and ligaments 
of the joint had suffered no extensive destruction. But, since these 

* This, in fact, is often observed before the pain or any other symptom. — Tr. 



572 DISEASES OF CHILDREX. 

favorable preconditions are the attributes of the fewest cases, this ter- 
mination belongs, therefore, to the greatest of rarities. 

(2.) Recovery, with diminution of the function of the joint, owing 
to the inflammatory process having brought about such morbid altera- 
tions that a perfect restoration is no longer possible. In such cases, 
when the osseous and cartilaginous parts have suffered in a compara- 
tively less degree, but the capsule, the ligaments of the joint, and 
the surrounding soft parts, on the contrary, have experienced a great 
deal of destruction, and the healing has progressed with contractions, 
adhesions, and fusions, it results in stiffness, with impaired mobility 
of the joint (false anchylosis), or, when the osseous parts and carti- 
lages have also been more seriously affected, and, by the formation of 
new bone during healing, become uniformly united, true anchylosis 
may ensue. The latter result is also subject to a number of operative 
procedures — as healing with at least some mobility is more advan- 
tageous for some cases, and is sought to be accomplished by surgeons 
through an operation. False anchylosis, in the just-mentioned views, 
not infrequently furnishes a cause for operative undertakings, while 
true anchylosis, on the other hand, when it is combined with more 
marked deformity, becomes the subject of a manual treatment. 

(3.) Healing, with luxation of the bones forming the joint ; in 
the course of the inflammation after the tendons and ligaments 
have been destroyed, as also after perforation of the capsule has oc- 
curred, luxation of one or more bones from their natural position will 
result through any, in most cases trifling, causes (luxatio spontanea). 
When such a dislocation has existed for some time, it seldom becomes 
a promising object for surgical interference ; only now and then, in in- 
flammations which have already expired, and when the dislocation has 
not existed for a very long time, can a successful result be looked for 
from a surgical operation. 

Therapeutics. — The treatment resolves itself into two parts : (1), in 
a general one, directed against the fundamental disease; and (2), in 
the topical against the local affection. 

In regard to the latter, a perfectly quiet and proper position of the 
diseased part is of the greatest importance, and the Ji?'st consideration 
of every treatment, if it is to be crowned with success. It has already 
been remarked that the patient will instinctively select a certain pos- 
ture for the limb ; but, since this position of the affected joint wiU 
generally be permanent throughout the entire course of the inflamma- 
tion, and in some cases will prove unfavorable to the future exercise of 
the limb, it is therefore necessary to pay especial attention that the 
position is such a one that, at the termination in anchylosis, the use- 
fulness of the limb will not be impaired in a too high degree. The 



GEXERAL DISEASES OF THE SECRETIONS. 573 

patient, as a rule, soon becomes accustomed to the direction given 
to the limb, although it is just the contrary to the one he had himself 
selected. 

Uninterrupted rest is to be maintained so long as there is any 
sign of inflammation, and only after it has entirely terminated can any 
movements of the limb, even with the utmost possible care and pro- 
tection, be allowed. 

The pains are best allayed by the internal use of narcotics, as also 
the local application of ointments containing morphine, etc. ; but, if 
they have become very intense, then we should not hesitate to use 
cold, or even to apply ice. 

Many remedies have been recommended as resolvents, to facilitate 
the absorption of the exudation. Those most frequently used are the 
preparations of iodine — iodide of potassium ointment ; Richter's solu- 
tion of iodine for pencilHng the j^art — iod. pur., kali hydroiod., aa 3 j, 
glycerine 3 ij. The use of mercurial preparation requires much 
caution. 

Johert has lately recommended nitrate of silver as an excellent 
remedy in chronic inflammations of the joints. At first an ointment 
containing argent, nitr. 3 j to adipis 3 j, of which from 3 ss to 3 j is 
rubbed in twice daily ; it is gradually made stronger, until it contains 
3 iij of nitrate of silver to § j of fat. Setons, issues, moxas, and the 
actual cautery, have been used as derivatives ; the latter, especially, 
has acquired a great reputation in Husfs hands. Nevertheless, the 
result falls far short of the expectations that have been entertained. 

Numerous baths are also employed for the treatment of the cachexia 
as well as for the local affection ; but these are only permissible with 
the understanding that the change of posture and movements will not 
cause the patient more harm than good. Iodine and bromine baths 
have acquired a certain amount of reputation ; baths, with common 
cooking salt, deserve especial recommendation on account of their 
simplicity and cheapness. Priesnitz^s method of treating joint-affec- 
tions may be added here, which, in its entire extent over the w^hole 
body, should be discarded on account of the small amount of strength 
the child has to spare in the exhausting cure ; but, locally to the affected 
joint, it deserves full consideration. Where suppuration exists, care 
should be taken to allow the pus to escape freely ; the sinuses are to 
be dressed with simple, unirritating apphcations. Abscesses develop- 
ing themselves in the vicinity of a joint, and bulging up under the 
integument, are to be opened as early as possible ; on the other hand, 
the opening of abscesses which are in connection wdth the joints, or, 
after having perforated the capsule of the joint, subsequently reach 
beneath the sldn, should be delayed as long as possible, if the strength 



574 DISEASES OF CHILDREN. 

of the patient is sinking and giving out, for then the process, as a 
rule, runs faster toward a fatal termination. 

"V^Hien purulent degeneration of the joint ensues, and there is no 
longer any hope, from the most appropriate local and general treat- 
ment, that anchylosis ^viil take place, and the circumstances be- 
come aggravated to such a degree that hectic consumption is appre- 
hended, then surgical interference comes into consideration as a der- 
nier ressort of saving the hfe of the patient, provided the general con- 
dition — upon which, of course, every individual case must be judged 
separately — allows an operation to be undertaken. In these cases 
there may be a question about the removal of the affected part of the 
bone — resection — or about amputation of the limb, or exarticulation. 

In joint-inflammations that have become totally chronic, the use of 
a graduated bandage upon the affected limb, with or without the sim- 
ultaneous employment of remedies to accelerate absorption, particu- 
larly the preparations of iodine, will be found to be of great benefit. 
ComjDression may be effected with flannel or ordinary bandages, or a 
plaster of paris or starch bandage is applied around the joint for this 
purpose, by which it is also kept in the desired position. Sinuses 
and ulcers about the joint do not serve as contraindications. All that 
is necessary in that case is to cut out holes in the apparatus corre- 
sponding to the size and position of the ulcers, and to remove the 
whole dressing somewhat oftener than when the skin is whole. If 
the anchylosis, so far as it hinders the use of the affected limb in a 
marked degree, affords causation for treatment, then, according to the 
nature of that condition, simple or serious operations wiU have to be 
resorted to. To the first belong local and general baths, douches, fo- 
mentation, supported by passive movements, apparatus, and instru- 
ments ; to the latter, the forcible breaking up of the adhesions and 
extensions, either by the aid of machinery or under anaesthetics, 
according to Langenheck''s precepts. Subcutaneous section of thick- 
ened aponeurotics, ligamentous structures, etc., may be ]3reviously 
performed to facilitate the operation. In bony anchylosis, resection 
of various-shaped pieces of bone may be resorted to. 

Scrofulous Iktlammatiox of the Hip-joixt [Coxitis Scrofur 
losa, Coxarthrocace, Coxalgia, 3£orhus Coxarum, Luxatio Sponta- 
nea^ FreiicilUges Hinhen^ Hip Disease). — This disease occurs by far 
the most frequently of all inflammations of joints, and attacks scrofu- 
lous children in various ages of life, very often at the time of the sec- 
ond dentition. It generally takes its rise from the bony parts of the 
joint — most frequently from the head of the femur — less so from the 
sj-novial membrane, or the surrounding soft parts. It presents varie- 
ties in its stages, according as the course has an acute or clironic char- 



GENERAL DISEASES OF THE SECRETIONS. 575 

acter. In the acute inflammation, violent pains quickly come on in 
tlie liip-joint and its neighborhood, which spread predominantly upon 
the inner side of the thigh down to the knee, and become aggravated 
upon pressing the hip-joint, or on attempts at walking. The latter 
are therefore carefully avoided ; the thigh is drawn up against the 
abdomen, and rotated slightly inward. The pains usually increase in 
severity at night, and often rob the patients completely of sleep ; con- 
jointly with it, as a rule, active febrile movements are present, which 
often reduce the strength remarkably rapidly. It is extremely diffi- 
cult for them to stand or walk, sometimes altogether impossible ; 
the child throws the weight of the entire body upon the sound limb, 
draws up the affected side of the pelvis, and is in danger of falling. 
The region of the hip-joint, particularly the buttock, appears more or 
less swollen, the fold is generally longer and less marked than on the 
other side. Both extremities are either equally long, or the diseased 
extremity appears somewhat shortened or elongated. When the in- 
flammation does not undergo resolution — the rarer case — it will pass 
over into suppuration attended by the most serious aggravations of 
the general and local phenomena; abscesses then form, either in 
close proximity to the hip-joint, or at some distance from it, commu- 
nicate with the purulent accumulations in the joint, finally break open 
after reddening the integument, and are the causes of keeping up an 
intense suppuration and purulent infiltration. In cases where the de- 
struction of the osseous parts goes on rapidly, the head of the bone 
becomes smaller and the acetabulum larger, thus giving rise to a dis- 
proportion of spaces, and, as a result thereof, we will have dislocation 
of the head of the thigh-bone, and an actual change of its relative po- 
sition in comparison with its fellow. Soon after the bursting of the 
capsule of the joint, the fever assumes a hectic character, the strength 
of the system sinks, the patients become notably emaciated, and the 
muscles of the hip and thigh weak and soft. They often succumb at 
this stage to the continuous consumptive fever, which may also be 
accompanied by pysemic phenomena, as the entire process may be of 
but very short duration. Only in rare instances does the suppuration 
ever grow less ; in such cases, small pieces of bone may exfoliate and 
be expelled, and the orifices of the abscesses then close up. 

In the chronic course of hip-joint disease, close observation Avill 
often show that the child, on walking, drags or draws one extremity ; 
it complains of slight fatigue or weakness of the limb; the walk, 
when active, becomes unsteady, during which, likewise, the greater 
part of the weight of the body rests upon the sound side of the 
pelvis and extremity. The pains are not intense nor continuous, 
vaguely course about the thigh, and are rheumatic in character; 



576 DISEASES OF CHILDKEN. 

not infrequently, they are present in the morning, disappear during 
the day, and reappear in the evening, accompanied by febrile ex- 
citement. Very little that is abnormal may be observed about 
the hip-joint. Still, if the patient is told to raise up the affected 
extremity, a slight rotatory movement of the thigh inward, along 
with a small degree of abduction, will be noticeable. These cir- 
cumstances, in the insidious course of the evil, may last for months 
(even years), and alternate also, frequently, with improvement and ag- 
gravation. 

After a certain period the morbid picture changes without any ap- 
parent decided external cause, and inclines more and more toward 
the acute form. The well-known pains in the knee come on, which 
are very intense in most cases, without, however, becoming aggra- 
vated on touch or pressure. These j)ains are explained by the sup- 
position that the external cutaneous branches of the obturator, or of 
the internal saphena nerve, are irritated. The walk becomes still 
more difficult, the patient limps, the toes only touch the ground, 
while the weight of the body comes to rest upon the extended sound 
limb. In the sitting posture the buttock only of the sound side rests 
upon the seat, and, when the patient desires to pick up some object 
from the floor, he only bends the sound knee, while the diseased 
extremity is kept stiff and extended. 

At a further stage of the disease certain symptoms supervene, 
which have given rise to the most varying views and significations, 
and which have already been alluded to above, namely, an elongation 
or shortening of the affected thigh in comparison with its fellow, 
without any change in the position of the bones, entering into the for- 
mation of the joint, having taken place. Formerly it was almost 
wholly assumed that the head of the femur was pressed out of the 
acetabulum by the exudation, and displacement of the femur thus 
produced, or it was drawn into the acetabulum by strong muscular 
contractions, and the extremity shortened. All evidences, however, 
tend to show that the supposed shortening or elongation is no 
actual condition but only an apparent one, produced by the sink- 
ing of the pelvic moiety on the diseased side, or through displacement 
upward of the pelvis on the affected side, with subsequently resul ting- 
curvature of the spinal column. For the purpose of clearly elucidat- 
ing this circumstance, and to avoid falling into a very possible error, 
certain accurate measurements are to be instituted ; but first it is 
necessary to bring both anterior superior spinous processes into the 
most direct line possible, the patient being on his back, and a rectan- 
gular line drawn from the xiphoid cartilage of the sternum, directly 
to its centre. Then both extremities should be placed in per- 



GENERAL DISEASES OF THE SECRETIONS. 577 

fectly exact positions, and both sides measured from the spinous pro- 
cesses to the internal condyle and internal malleolus. 

At this stage, i. e., while the deformity is only apparent, the disease 
may also be brought to a stand-still and cure, and the phenomena of 
shortening or leng-thening disappear, provided no alteration in the con- 
figuration of the pelvis and spinal column has taken place, sufficient 
to prevent the peMs from regaining the straight position. 

But, on the other hand, if the disease goes on unchecked, a more 
or less marked swelling of the fundament and region of the hip-joint 
takes place, the integument becomes red and soft, fluctuation is dis- 
tinctly felt, and these conditions are soon followed by the breaking of 
the abscess. This, however, does not always take place in the neigh- 
borhood of the joint, the pus may tunnel its way downward, and make 
its appearance in the region of the knee, or even still lower down. 
It may also perforate the capsule of the joint. In the majority of 
cases, this occurs at its posterior or under side, where on the one 
hand it is less dense, and on the other, also, the greatest amount of 
pressure is exerted by the head of the femur, especially when the 
patient is left to himself to select his own position. Pus may some- 
times be observed escaping from the cavity of the joint through the 
communicating place, with the bursa beneath the iliacus internus and 
psoas magnus muscle, into the latter, and thence into the pelvic 
cavity; in addition it may also run into the pelvic space by perforating 
the ilium along the gluteal group of muscles. The sinous openings, 
left after the bursting of the abscesses externally, are generally sur- 
rounded by spongy, readily-bleeding granulations, which project above 
the level of the skin ; extensive ulcers, also, not unfrequently form upon 
the skin and subcutaneous cellular tissue at the places corresponding 
to the perforations. 

In progressive destruction of the osseous substance of the bones, 
entering into the formation of the joint, there originates a shortening 
of the neck of the femur, and an enlargement of the acetabular space, 
thus resulting in a disproportion, which is the fundamental condition 
to the process called luxatio spontanea, and is attended by true 
shortening or elongation of the thigh, in comparison to its fellow. 
In the advanced carious process, dislocation of the head of the 
femur or the residue thereof very frequently occurs by the mere alter- 
ing of the position in bed, by raising the patient, or by the energetic 
contractions of the extensor muscles, and may be effected in different 
directions. Most frequently, however, the luxation takes place up- 
ward and backward upon the dorsum ilii, because the head, by the 
position of the thigh, comes to press mostly against the posterior bor- 
der of the cotyloid cavity, and its carious destruction is completed at 
37 



578 DISEASES OF CHILDREN. 

an earlier 23eriod, and the head of the bone then has but a very slight 
impediment to overcome. "Wlien that portion of the ihum, upon which 
the ulcerating caput femoris comes to rest, is also attacked by carious 
disease, perforation of the ilium, with penetration of the head into the 
pelvic cavity, may take place, although this event may also happen, 
without dislocation, by perforation of the floor of the acetabulum. 

Besides the usual form of dislocation of the head of the thigh- 
bone, it may also occur into the ischiatic notch, obturator foramen, 
or upon the horizontal ramus of the pelvis; these are, however, 
very rare and exceptional instances. Total exfoliation of the head of 
the bone, and its expulsion through a large sinus, have also happened 
in the experience of some surgeons ; in favorable cases a cure may 
take place after the-se processes, not, however, without very great 
deformity. 

"When an arrest in the progress of the disease, and recovery from 
the evils under consideration after luxation, have taken place, the just- 
described effects will remain behind and impair the usefulness of the 
limb in a high degree. In fortunate cases a kind of joint-cavity forms 
at a future period near the old one, in which the head is able to per- 
form some evolutions, but in most it is held firmly in its new place by 
adhesions and newly-formed structures. 

Most frequently, however, the dislocation of the head of the femur 
is the precursor of the last stages of the disease. The suppuration 
constantly becomes more and more profuse, not infrequently large 
portions of the integument slough off, and the extremity, in conse- 
quence of pressure on the veins or obstructions mthin them, becomes 
oedematous. The fever assumes more and more the hectic character; 
shiverings or actual chills come on, and the patients die exhibiting the 
picture of general consumption. 

In the acute form of inflammation of the hip- joint, as also in the 
fully-developed disease, there will be no difficulty whatever in forming 
the true diagnosis ; in the chronic course, on the contrary, it may, in 
its incipient stages, be entirely overlooked or confounded with other 
processes. At the commencement of the disease it is not unhkely to 
be mistaken for rheumatic affections, or for coxalgia, still an accurate 
observation of the dehneated symptoms, and the absence of phenomena 
peculiar to those diseases will plainly point out the true diagnosis, 
although the general state of the system had not yet directed any 
special attention to the local trouble. 

Therapeutics. — The most important part in the treatment of coxitis 
is absolute rest of the lower extremity and hip-joint, and this indica- 
tion is to be carried out loith the limb in the extended position. For 
this purpose the same apparatus is advantageously resorted to as is 



GENERAL DISEASES OF THE SECRETIONS. 579 

used in fractures of the neck and body of the femur, and preferably 
Tvith double sphnts for the outer sides of both extremities, which 
should reach up to the axillag, and be united below by a foot-board, 
while the pelvis is secured to the apparatus by a strap or girdle. No 
matter how much the patients are opposed to this apparatus at first, 
especially if they have been allowed to retain the thigh in the flexed 
and adducted position which they had themselves selected, they will 
readily become accustomed to it, especially if, at first, it is only ap- 
plied for a while and gradually kept on for a longer time. 

Starch and plaster-of-paris bandages have also been used with ad- 
vantage for the purpose of keeping the hmb and hip-joint immovable : 
these may especially be used in the milder cases, for in these the dis- 
placement of the pelvis does not require so great a counteracting 
power as in the severer.* 

* A variety of apparatus has been invented for the purpose of securing complete 
immobility to the affected hip-joint. M. Bonnet's grand appareil^ and Bauer's 
wire-breeches — which is a modification of the first — are so constructed as to fit to the 
pelvis, both thighs, legs, down to the feet. The apparatus being well fitted and padded, 
is secured to the parts by bandages and leather straps, thus securing perfect immo- 
bility for the lower half of the person. Barwell, of London, however, finds fault 
with this appliance, on account of its interfering with the movements of the sound limb 
and spinal column, without securing perfect immobility to the diseased hip-joint, and 
has had a splint constructed which simply restrains the movements of the affected 
limb. It consists of a pelvic portion made of wire gauze and reaching from the spine 
of one ilium to the other, thus embracing both sides of the pelvis and the sacrum, 
wide enough to reach from the crista ilii to the trochanter on the sound side, 
and extending from the pelvic band on the diseased side down the outer aspect of 
the thigh as far as the knee. The instrument is also secured to the trunk by an 
india-rubber band surrounding the body. It should be well lined and padded, and 
retained in place by bandages and adhesive plaster. As regards the use of counter- 
irritants, there is great diversity of opinion. No doubt seems to exist as to their 
usefulness in the early stages. Thus, in subacute synovitis of the hip-joint, blistering 
and the use of savine ointment will suffice, but, when the severe symptoms of ostitis 
show themselves, the more potent cautery or caustics are required. Potassa fusa 
is frequently resorted to, but at this stage is properly superseded by the potential 
cautery. The splint should not be removed until some period of time has elapsed 
after the subsidence of all symptoms of inflammatory action, and after its removal 
the patient should remain in bed for a few days, and gradually undertake the exer- 
cising of the limb. 

At a further stage of the disease, when lengthening, with abduction and flexion, 
has existed for some time, the patient will sufl'er intensely from a very peculiar and 
painful clonic spasm of the muscles of the thigh, aggravated at night, depriving 
him of all sleep, and indirectly undermining the health. Narcotics, even in very large 
doses, have little if any quieting effect, so that, generally, it is better to place the limb 
in a straight position and retain it by counter-extension, a measure easily accom- 
plished, as the pain is chiefly due to spasmodic muscular contraction, caused by ner- 
vous irritation, and is overcome by the extension. If the deformity is slight, and the 



580 DISEASES OF CHILDREN. 

Lately, resection of the femur has also been successfully performed. 
The operation is comparatively easy, as, the ligaments and capsule of 
the joint having been almost wholly destroyed by the various processes, 
one long incision will suffice to reach the head of the bone ; it is then 
turned out of the socket and sawed off by the ordinary or chain saw. 
Other methods of operation are based upon the substitution of a trian- 
gular or an elHptical incision for the straight one, but in that respect 
no positive rules can be laid down, for the sinuses, which are invariably 
present, will materially affect the direction that is to be given to the flap. 

Where a cure has resulted with dislocation of the head of the bone, 
the deformity and hinderance in the use of the limb may be sought to 
be remedied by surgical operations. Where the dislocation is but of 
short duration, the usefulness and direction of the limb may, in a meas- 
ure, be improved by an operation best adapted to the individual case, 
and afterward bettered still more by a properly-adjusted instrument. 

ScEOFULOus lNTLAMMATio:Nr OF THE Knee-joint ( GoncD'throccice, 
Gonalgia, Tumor Alhus Genu — White-swelling of the JS}nee). — This 
disease takes its starting-point either from the bony parts of the joint, 
and preferably from the condyles of the femur, less frequently the 
head of the tibia or — but, in fact, oftenest — from the synovial mem- 
brane, with or without the ligaments of the joint. The phenomena 
vary according as to whether the disease occurs in an acute or chronic 
form ; in the former case they may manifest themselves in an intensely- 
rapid and violent manner, and in a short time terminate in suppuration 
of the joint, or even fatally — in the latter, the signs are often at first very 
slight, almost unnoticeable, and only after a while become aggravated. 

Symptoms. — The affection begins with a sensation of stifihess and 
some impaired mobility of the joint ; flexion is difficult, while exten- 
sion, on the contrary, is generally hindered to a less degree. Swelling 
of the joint, which may be proved by comparative measurements, is 
early recognized by the depressions to both sides of the ligamentum 
patella, as also by the knee-joint appearing fuller and larger. The 

case be in its primary stage, the splint alone may be sufficient to overcome the con- 
traction, while in aggravated cases tenotomy may be required. 

Should fluctuation be discovered in the joint, Bauer, Barwell, and others, recom- 
mend evacuation of the pus, either by opening the capsule "with a tenotome, allowing 
its exit into surrounding tissues, or the use of a trocar and canula. The latter measure 
seems preferable, inasmuch as by it the fluid may be seen and examined, and the 
diagnosis confirmed as well as the treatment aided. Finally, in the third stage of the 
disease, where there is great deformity from strong and rigid contractions which can- 
not be overcome by counter-extension, etc., aided by chloroform, and there is intense 
suffering from muscular spasms, tenotomy must be resorted to, after which the limb, 
being placed in position, may be retained so by means of the hip-joint splint. For 
further details, the student is referred to the standard works on surgery. — Tk. 



GENERAL DISE^iSES OF THE SECRETIONS. 581 

temperature of the part is usually somewhat increased. As the dis- 
ease jorogresses, the leg gradually becomes contracted upon the thigh, 
and the movements more painful, especially flexure of the limb. 
The pains soon become constant, even without any attempts at motion. 
At first they are of a dull character, after a w^hile become more intense 
and sharper, and extend down to the foot, the tumefaction increases, 
generally has a peculiarly-elastic feel, but does not fluctuate ; the in- 
tegument retains its color, and is mostly intense and shining. When 
suppuration begins within the cavity of the joint, and the abscesses 
rapidly increase in size, the integument becomes red, and distinct fluc- 
tuation is felt, more or less plainly, in the degree in which the pus 
reaches the skin ; the pains become so aggravating as to rob the pa- 
tient completely of all rest and comfort. The abscesses burst either 
in the circumference of the joint, or the pus sinks downward along the 
leg, and in some cases makes its appearance in the region of the ankle. 
In addition, abscesses have been observed to break on all parts of the 
leg, most frequently on its anterior surface. The pus, facilitated by 
the position of the extremity, has also been seen to travel for a dis- 
tance upward upon the thigh, and to make its appearance there. 
When the process is attended by carious destruction of the bones en- 
tering into the formation of the joint, and ulceration of the capsule and 
the contiguous soft parts, dislocation of the bones may likewise ensue 
in this condition, and this may happen especially to the tibia, which 
will present a partial or total luxation from its natural position. 

The process may come to a stand-still, at every stage of the stated 
alteration in the course of the disease, in which, according to the ex- 
tent of the pathological alterations, more or less impairment of motion, 
and of the configuration of the joint, will ensue. In most instances 
there results — when the treatment did not prevent this termination — 
a cure, with union of the joint ends — anchylosis : in more favorable 
cases, where the treatment was more successful, the result will be the 
formation of fibrinous and ligamentous bands, following inflamma- 
tions which took their issue from the synovial membrane, and were 
unattended by any serious destruction of the cartilages — false anchy- 
losis : in the unfavorable, complete bony union of all the bones of the 
joint following carious inflammation of the bones, with exfoliation of 
the cartilages — true anchylosis. 

If the disease goes on without displaying any tendency to abate, 
and enters its last stages, the leg will become oedematous, suppuration 
will be profuse, the general phenomena assume a more and more 
alarming character, and death ensue either from exhaustion or puru- 
lent infection. 

Therapeutics. — The principles already laid down in the treatment 



582 DISEASES OF CHILDREN. 

of inflammation of the Hp-joint are also applicable here. Of the seri- 
ous surgical operations, amputation of the thigh will claim the main 
consideration ; resection of the knee-joint will hardly ever be practi- 
cable, on account of the extensive osseous surfaces, which will have 
again to undergo suppuration, and the small prospect of recovery 
which will attend this operation. 

ScEOFULOus Inflammatiojs" of the Axkle-Joint [Tumor Albus 
Articuli Pedis. JPodarthrocace). — This disease, which is of tolerably 
frequent occurrence, usually commences by a very moderate, and after 
a while a more intense, growing, fixed pain either on the anterior sur- 
face of the ankle-joint or on one of the lateral regions, seldom embra- 
cing the entire joint. Motion, at first, is but little hindered ; soon, how- 
ever, it becomes so difficult that the foot is dragged along, the patient 
being unable to bring it down flat upon the floor, and every false 
step, every collision with firm objects, even the stepping upon firm 
bodies, stones, etc., induces a painful sensation of the joint. An elastic 
swelling, covered by normal-colored skin, soon manifests itself about 
the ankle-joint, by which the spaces beneath the malleoli become filled 
out, and the entire region of the joint more voluminous. The pain is 
constant, of a dull or tearing character, and radiates over the foot. 

At a further stage of the malady the skin becomes reddened and 
the swelling softer, fluctuation is detected at one or more places, in con- 
sequence of the purulent accumulation either direct from the ankle- 
joint or from an abscess that has originated in its vicinity, and which 
soon communicates with the cavity of the joint. The pains attain to 
their acme before the abscess breaks ; when that has occurred, they 
decline in intensity. Through the fistulous openings, of which quite 
a number are sometimes seen about the joint, the opened cavity 
of the joint may readily be reached with a probe, or the probe may 
encounter carious portions of bone belonging to the tibia or tarsal 
bones, while from it a very badly-smelling discolored pus, which is also 
mixed with crumbly granular pieces of tubercular masses and parti- 
cles of bone, escapes. The fistulous openings are indebted for their 
origin to abscesses that have formed in the soft parts around the 
joint, and which, in most instances, will be found to penetrate clear 
into the diseased cavity of the joint. 

At a further stage, if the disease has gone on unchecked, the foot 
becomes misshapen and deformed, for its anterior part generally ema- 
ciates, the region of the joint thereby appears disproportionately en- 
larged, and, in addition, is drawn upward in consequence of con- 
traction of the tendo Achillis, after the manner of talipes equinus. 
The disease, as a rule, runs a very slow course, with acute and sub- 
acute exacerbations ; sometimes heals with deformity and permanent 



GENERAL DISEASES OF THE SECRETIONS. 583 

impairment of motion, but, under serious disturbances of the general 
system, from profuse suppuration and exhaustion, may also terminate 
fatally. 

Therapeutics. — Besides amputation of the leg, which, in this form, 
may come into consideration, it may also be a question about exsect- 
ing the carious ankle-joint, if the disease has only involved the lower 
joint-end of the tibia, and the upper surface of the astragalus. 

ScKOFULOFS Intlammation OF THE Elbow-joint [OUnarthro- 
cace). — In strumous subjects, the elbow-joint is not infrequently the 
site of inflammation, which generally has its starting-point in the 
synovial membrane, and attacks the bony joint-ends ; sometimes, 
again, it first starts from the spongy portion of the bones entering into 
the formation of the joint. The disease, as a rule, begins with a 
slight degTee of difficulty in exercising the joint, and with mild pains ; 
both phenomena gradually become aggravated, while round about the 
joint a swelling forms, which at first is tolerably dense and elastic, 
but, after a while, becomes soft and breaks open at one or more places. 

The forearm is bent more or less upon the upper arm, and has a 
position midway between pronation and supination ; the whole ex- 
tremity not infrequently presents a peculiar appearance, for the fore- 
arm is atrophic, the upper arm also, on account of its inactivity, suffers 
its muscles to become emaciated, while the region of the joint is seen 
to be swollen into a spindle or globular form. The destruction within 
the joint, as a rule, may be easily ascertained by the examination with 
the probe through the sinuses, as these, in most instances, do not form 
any very long tracts, but lead directly to the bone. 

The general phenomena vary in the manner often already de- 
scribed, according as to whether the course has an acute or chronic 
character ; hectic and pyagmic fever less frequently become developed 
from this kind of scrofulous inflammations than from those previously 
described, but, nevertheless, do likewise occur. When the disease 
goes on toward recovery, a cure may take place, with more or less 
deformity and anchylosis. Dislocations of some of the bones from 
their normal position do not often occur, even in extensive destruction. 
Most frequently, a luxation of the ulna backward, or a displacement 
of the head of the radius inward, takes place. 

Therapeutics. — Besides amputation of the upper arm, which may 
come into consideration in very violent inflammations of the elbow- 
joint endangering life, resection of the carious bones is yet to be men- 
tioned, which is not infrequently resorted to in exhaustive suppm-ation, 
to save the life of the patient, or to shorten the morbid process in the 
joint. Generally a longitudinal incision, running parallel with the 
inner border of the olecranon, commencing two fingers' width above it, 



58tl: DISEASES OF CHILDREN. 

and running downward, w^ill be sufficient for the removal of the dis- 
eased bones ; where this does not answer, a complicated incision, the 
shape of which depends mostly upon the existence of the sinuses, will 
be necessary. In all methods of operation, proper care should be taken 
to preserve the ulnar nerve. 

GeXEEAL TuEATilEXT OF TuBEECULOSIS AN^D SCEOFULA. — In the 

great importance which, according to my views, is to be attached to 
the hereditary disposition, as the chief cause, there can be less of a 
question of preventing the outbreak of the cachexia, than of attaining 
a possibly mild, favorable course of the various local manifestations. 

Scrupulous avoidance of all digestive disturbances, and residence 
in well-ventilated rooms, are the two chief points upon which the phy- 
sician has to insist, in children the progeny of tuberculous parents. 

They should remain for a long time at the breast of a healthy 
wet-nurse, and be weaned Avith the utmost caution. Subsequently, all 
nutriments which produce flatulence are to be avoided. The chief 
articles of diet in the first ten years should be milk and milk soups, 
beef broths and juicy meat, tender vegetables, and plenty of ripe 
fruit. Potatoes should not be allowed in large quantities ; the bread 
should be well baked. Children should get nothing but water for a 
drink. Small quantities of beer can do no harm ; ^vine and other 
spirituous liquors, however, should be strictly prohibited. 

Acorn coffee is especially adapted as a drink at breakfast, and 
pure milk is to be substituted for it when the patients are no longer 
disposed to take it readily ; genuine coffee should not be used under 
any circumstances. 

No departure need be made from this diet, so long as the strumous 
affections, which happen to supervene, are feverless ; when febrile ex- 
citement comes on, the instinct, which in children is even keener than 
in the adult, will forbid it of itself. 

As regards the residence, a sunny sleeping and sitting-room, as 
large as possible, and capable of being thoroughly ventilated, is to be 
urgently recommended. In summer the children should be out the 
entire day in the fresh air ; in winter, at least two hours every day. 
Frequent tepid-warm, and, still better, cold baths and ablutions are 
the best means of protecting the children against colds, and the so- 
frequent bronchial catarrhs. Sea-baths and salt-water spring baths 
are also of especial benefit to scrofulous children. 

In summer they should live in the country ; in winter, in large, 
spacious apartments. The residence in warm climates during the cold 
seasons of the year has, it is true, the great advantage that the chil- 
dren are there able to be much more out in the fresh air. But since 
this change of place has to be carried out every year, if, in the sue- 



GENERAL DISEASES OF THE SECRETIONS. 585 

ceeding years, the children are not to be subjected to the danger of 
suffering decided harm, they thereby become accustomed from their 
earliest youth on to an unsettled, roving hfe, and regard themselves 
as eternal patients. That there is no happy prospect in store for such 
hot-house plants needs scarcely any additional assurance. 

Of the remedial agents, cod-liver oil without doubt deserves the 
first name on the Hst. It is contraindicated in febrile conditions, in 
anorexia, and in diarrhoea ; the latter condition it is of itself apt to 
induce in the hot summer season. Aside from that, it is taken with 
the greatest advantage for years by all scrofulous, and also well-pro- 
nounced tuberculous children. 

It is best to give it one or two hours after breakfast:, in quantities 
of from one-half to one tablespoonful — a little coffee or a small piece 
of sugar is given afterward. On the whole, most children do not re- 
quire to be remunerated at all with any jDarticular dehcacies for taking 
the oil, for usually it is not repulsive to them in the least, and they will 
themselves remind the nurse to give it to them if she has once for- 
gotten to do so. It is well to inform the relations, at the very outset of 
the cure, that an improvement can only be derived from years' constant 
use of the remedy, and that it has to be given for many months, even 
though at first no change or no aggravation should have taken place. 

In well-nourished, but, for the most part, strongly-tainted, scrofu- 
lous children, small doses of tincture of iodine, one or two drops, to 
the ounce of the oil, may be added. Still, I would never advise a 
long-continued, internal treatment with iodine. Springs containing 
iodine and bromine, of which Heilbronner stands at the head of the 
list, next Kreuznach, are of decided benefit in scrofulous children 
free from bronchitis, but totally contraindicated in emaciated children 
with suspicious bronchitis. 

If the cod-liver oil is not tolerated, or the child refuses to take it, 
some substitute must be looked for which will take its place. A tea 
made from walnut-leaves seems to be the most advantageous, and of 
which two or three cupfuls should be given daily. A decoction of 
hops, or a calamus infusion, is also relished by some children, but 
many others refuse to take either on account of the intense bitterness. 
To children with excessively-pale lips and mucous membrane, mineral 
waters containing iron, or easily-assimilated preparations of iron, for 
example, ^ martis pomat.,* must be given. 

All exhausting treatment, whether it consists in abstraction of 
blood or emetics^ in purgatives, in antimonials or mercurials, induces, 
in all cases, an aggravation of the dyscrasia, and is therefore to be en- 
tirely avoided. 

* Malate of iron. — Tr. 



586 DISEASES OF CHILDREN. 

Unfortunate, finally, are tlie effects whicli result from surgical 
operations on scrofulous bones. The same diseases of the bones, for 
%yhich the operation was undertaken, usually spring up anew on the 
wounds of the bones, and the process is but little retarded, in spite of 
all the torture and pains. 

(3.) Heeeditaet Syphilis. — Syphilitic parents beget children, 
who are either born Tvith the signs of the malady, or, at least, pre- 
sent them in the first few months of life. Prognostically, it is of im- 
portance to distinguish whether the children bring with them the de- 
veloped sj^hilis into the world, or only become affected with it some 
time thereafter. 

Children, in whom syphilis has broken out in iitero, are mostly de- 
livered prematurely and dead, and surely perish soon after dehvery if 
they came into the world with pemphigus vesicles. But the progeny of 
syphilitic parents, born apparently healthy, who only manifest signs of 
inherited syphilis after many weeks or months, very frequently recover 
under an appropriate treatment, and may develop perfectly, without 
any further cachectic troubles. 

Before we enter more minutely into the etiological question, it 
may prove advantageous to first analyze the morbid alterations be- 
longing to syphilis. 

Symptoms. — Inherited syphilis manifests itself: (1), upon the 
skin; (2), upon the mucous membranes; (3), in the subcutaneous 
cellular tissue; (4), in the muscles and bones; and (5), in the inter- 
nal glandular organs. 

(ad 1.) Shin. — SyphiHtic eruptions of the skin (the syphilides) 
are divided into (1), maculous 2Mdi squamous ; (2), papulous ; and 
(3), pustulous and bullous. 

To \hQ first form 

JRoseola syphilitica belongs. By this we understand small spots, 
of the size of lentils up to that of split peas, of a coppery color. They 
appear simultaneously upon large tracts of the surface of the body 
as bright-yellow or yellowish-red spots, primarily without any alter- 
ation of the epidermis of the affected parts, and without any indura- 
tion or elevation over the parts of the integument that are still sound. 
In time, however, they become slightly elevated, the color turns to 
copperj^, and they appear as if ground off, or, in other cases, become 
covered with fine white scales. If the patient is subjected to an anti- 
s}"philitic treatment, they will disappear entirely, but, if nothing is 
done, they will become more and more infiltrated, the epidermis either 
corrugated or dry, the crusts begin to exhale serum, and the spots 
covered -with yellow scabs. 

On parts of the integument that are constantly soiled with the al- 



GENERAL DISEASES OF THE SECRETIONS. 587 

viae discharges, as on the nates, and the posterior surfaces of the thighs 
and extremities, excoriations often form, and finally, also, deep ecthy- 
ma-like ulcers. 

Even the unaffected portions of the skin never preserve the nor- 
mal color and smoothness. They exchange their rose-red color for a 
smoky-grayish one ; this is strikingly seen on the face, and still more 
so on the forehead. The integument in many places becomes wrin- 
kled, in consequence of the emaciation which invariably ensues in 
sj^hilis. The palms of the hands and soles of the feet seldom re- 
main intact; a serious desquamation soon takes place upon them, 
and, in children who often handle the dirty sugar-teat, deep ulcers 
form on the palms of the hands. This preference of the syphilides 
for the last-mentioned parts of the integument is of great importance 
in the diagnosis, for the other non-syphilitic eruptions spare these 
very parts. 

The second form^ papulous^ scarcely ever exists by itself, but is 
complicated either with the first or third form, bullous. Syphilitic 
papules (lichen or strophulus syphihtica) are of a brownish color and 
hard, without any red areola, in most instances dispersed, and are 
likewise oftenest found on the palms of the hands and soles of the 
feet. They are not characteristic enough to allow the diagnosis of 
syphilis to be based upon them alone without any additional symp- 
toms. If no treatment is instituted, they will remain unaltered for a 
long time, grow more and more numerous, are destroyed in many 
places by scratching, and then represented by larger or smaller irregular 
ulcers. But, if a proper treatment is carried out, they will complete- 
ly disappear in a short time ; this is explained by the slight morbid 
derangement they had produced. 

The third fonn^ bullous, and pustular, is the most mahgnant, and 
occurs only in the very aggravated stages of the cachexia. It is repre- 
sented by 

Pemphigus Syphilitica. — By this we understand yellow, yellow- 
ish-green, or brownish purulent blebs, of the size of a hempseed up 
to that of a bean, surrounded only by a narrow areola. Their con- 
tents are turbid, purulent, of an alkaline reaction. They occur mostly 
in an isolated form, coalesce only on very few places, and these are 
also most surely found upon the palms of the hands and soles of the 
feet. These pustules either collapse after several days, and dry up into 
thin crusts, or they burst, their contents escape, and an intensely-red- 
dened cutis becomes visible after the epidermis has exfoliated. After- 
ward the sore discharges but very little, so that hardly any crusts 
form, and the garments are but little soiled. It is not possible for 
deep ulcerations to form, for the simple reason that the subjects 



588 DISEASES OF CHILDREN. 

do not live long enough for that purpose, but collapse rapidly, and per- 
ish, T^dthout any additional sickness, under weakness and exhaustion. 

The prognosis, in this bullous exanthema, may be put down as 
fatal with the utmost certainty. Children who bring the developed 
pustules with them into the world die in the first few days after de- 
livery ; but, when they acquire them a little later, between the third 
and eighth day of life, they may live for a few weeks, but ultimate- 
ly die almost unexceptionally. That form of congenital sjrphilis, 
which, according to ZeissVs extensive experience, almost entirely 
manifests itself in the form of pemphigus, is invariably fatal. 

It is a remarkable fact that syphilis, in the great majority of these 
cases, descends from the father, and that the most careful examina- 
tion of the mother leads to no positive results, so that the connection 
betw^een these exanthemata and syphilis has often been doubted. 
The doubts have mainly arisen in lying-in-houses, where the affected 
fathers very naturally could seldom be seen, while, in private practice, 
the previous and present state of health of the father can readily be 
ascertained. In the latter case it becomes apparent that the father 
invariably suffers, or at least had suffered, from secondary syphilis. It 
has often been observed that, after the father had subjected himself 
to a thorough anti syphilitic treatment, the children then generated 
come into the world normal, without any sign of syphilis whatever, 
and subsequently also remained well. 

Besides these pathognomonic pemphigus pustules, there is yet a 
pustular eruption which occurs at a later period in syphilitic chil- 
dren, but these pustules are situated upon a red, hard base, and, 
after they burst, leave behind deep lardaceous ulcers (ecthyma pus- 
tules). 

The cutaneous ulcers and rhagades, which only break out after 
birth, are the most characteristic lesions of syphilis ; they occur by 
special preference at the angles of the mouth, on the margins of the 
lips, and around the anus and genitals. The ulcers on the hps ajre 
flat, have a yellow, but slightly-indurated base, and are strictly con- 
fined at first to the red margin which hems the lip. Not till after 
some time do they grow beyond their original limits, and involve the 
adjacent integument, particularly the lower lip, where the epidermis 
is softened, by the food and sugar-teat. 

By rhagades, cracks, fissures of the lips in the direction of the nat- 
ural cutaneous folds, are understood. They sometimes originate in 
perfectly-healthy lips, generally, however, the ulcers just described 
are present, from the crusts of which the lips become brittle, and, when 
they are much stretched, as they necessarily must be every time the 



GENERAL DISEASES OF THE SECRETIONS. 589 

child cries, it causes them to crack and break. The little fissure is 
next infected by the pus from the ulcers, and tolerably deep, yellow 
erosions result, which bleed freely every time the lip is stretched, and 
for the same reason also heal extremely slowly. 

The fissures are also met with at the nares, though less frequently 
than about the mouth, as also about the anus and vulva in girls, and 
occasionally also at the angles of the eye. Those of the lips have an 
additional particular importance, namely, by them a syphilitic nursling 
may most surely and directly infect a healthy wet-nurse. 

Finally, as regards the cutaneous secretion, badly-smelling perspi- 
rations over the entire body, especially on the head, occasionally occur 
in syphilitic children. They also disappear as soon as the cachexia is 
eradicated from the system. 

(ad 2.) Mucous Membra7ies. — Swelling of the nasal mucous mem- 
brane is the first manifestation of hereditary sjrphilis, and does not ap- 
pear for some weeks after the delivery. Children thus afi"ected breathe 
through the open mouth, and snore while nursing. No morbid altera- 
tions are to be observed on the external surfaces of the nose, but the 
mucous membrane appears reddened and tumefied. A purulent dis- 
charge, coryza syphihtica, sets in after this swelling has existed for 
several days, the pus at first is muculent, and subsequently becomes 
sanguinolent, ichorous, eroding the upper lip over which it flows down. 
The spreading serpiginous ulcers which soon form may finally attack 
the bone, and cause necrosis and exfoliation of the vomer, the turbi- 
nated, and the ethmoid bones. When the subjects surmount such an 
intense syphilis, the nose at least will be destroyed, and the face dis- 
figured for life. 

The same flat, shallow ulcers originate upon the mucous memhrane 
of the mouth, and upon the tongue^ as on the margins of the Hps ; 
they never penetrate deeply, and readily cicatrize, if a proper treatment 
has been instituted. 

The fissures and ulcers about the anus, on the vulva and prepuce, 
have already been spoken of. Leucorrhoea and ulceration of the 
vagina occur tolerably often. Otorrhoea and ophthalmoblennorrhoea 
in syphihtic children difi"er only by their great intensity from the non- 
syphilitic. In this ophthalmoblennorrhoea both corneoe soften in the 
shortest time, and the process terminates extremely unfortunately, with 
phthisis bulbi. 

(ad 3.) Suhcutaneous Cellular Tissue^ — In many syphilitic children 
small abscesses form in the subcutaneous cellular tissue, which have 
no connection with the lymphatic glands. Whether the abscesses are 
opened with the lancet, or whether they break spontaneously, the ori- 
fices, in all instances, become ulcerated, and cicatrize only after a long 



590 DISEASES OE CHILDREN. 

time, witli intensely-colored puckerings. Ulceration of the nails 
(onychia) is very often observed on many fingers and toes at the 
same time. These processes are also very tedious, especially when 
the fingers come a great deal in contact with the sugar-teat ; the new 
nail then becomes rough, uneven, and misshaped. 

The lymphatic glands, in the neighborhood of syphilitic ulcers, do' 
indeed swell up consecutively ; they seldom, however, pass over into 
suppuration. In general it may be said that the lymphatic glandular 
apparatus of children is much less affected by syphilis than by scrofula 
and tuberculosis. 

(ad 4.) Muscles and Sones. — In very severe syphilis, which de- 
velops itself several weeks after birth, paralysis of the upper, less fre- 
quently of the lower, extremities occurs. These paralyses do not al- 
ways extend over an entire extremity, nor are they always complete, 
for often a slight capacity of exercising some of the muscular groups 
remains behind. 

The bones participate in hereditary syphilis very rarely only. 
Congenital fragilitas ossiura, in which all the tubular bones may be 
broken into fragments with the least amount of power, and which 
naturally is only met with in still-born, or in children dying soon after 
delivery, has been claimed to be connected with syphilis of the parents. 

This process, on the whole, is extremely rare, and, in the cases so 
far observed, the existence of syphilis was not by any means demon- 
strated in a satisfactory manner. 

Periostitis and necrosis of some portions of the bones, a very usual 
process in secondary syphilis of the adult, occurs but very seldom in 
hereditary syphilis of the new-born child. 

(ad 5.) Glandular Internal Organs. — Abscesses in the thymus 
glands, which have already been treated on page 281, are very much 
doubted as to being sjrphilitic, for the physiological cavities, which 
form in the atrophy and absorption of this gland, can scarcely be dif- 
ferentiated from abscesses. 

*In still-born children, the progeny of syphilitic parents, true 
abscesses are observed in the thymus gland in some rare instances ; 
it is, however, necessary to guard against the possibihty of mistaking 
the physiological cavities which contain a white fluid, and which occur 
in all children, for abscesses. The contents of the former always react 
acid, those of the latter, like pus, alkaline. In general, it should be 
observed that, in most children who die from hereditary syphilis, no 
purulent cavities of this kind can be found. I have abeady dissected 
at least a dozen such children, but only once found a cavity which 

* This paragraph was accidentally omitted from the section which treats of the 
affections of the thymus gland, page 281. — Tr. 



GENERAL DISEASES OF THE SECRETIONS. 59I 

resembled more an abscess than a physiological cavern ; the chemical 
test was unfortunately omitted. Bednar has also observed cystic 
formations in the thymus of syphilitic children. In some cases, he 
found cysts of the size of beans, filled with clear, yellowish fluid, and, 
in others, the whole lobes were converted into two large, yellow 
cysts. 

The morbid alterations of the hver have already been described on 
page 210. In the lungs, spleen, and Iddneys, gummy tumors of a 
specific character have been found. Most of the children thus affect- 
ed come into the world with a bullous eruption, and invariably die in 
a few days. 

CoTJESE AXD Termination^. — Ks> soon as the first signs of he- 
reditary s}"philis have appeared, which commonly happens, with 
the exception of congenital pemphigus, in from one to six months 
after delivery, the child begins to lose flesh, becomes restless, and 
soon acquires the characteristic, smoky appearance of the skin. Chil- 
dren, who are about to be brought up by hand, succumb usually to 
ansemia, or to a supervening intestinal catarrh. Children at the 
breast, under a proper treatment, recover tolerably often. The later 
the syphilis comes on, the more favorable the prognosis ; the earlier, 
the more unfavorable. 

Etiology. — In the great majority of cases hereditary syphilis de- 
scends from the father, not from the mother. If the mother is afflict- 
ed with secondary syphihs, the pregnancy will hardly ever go on to 
its natural conclusion ; an abortion, or, at least, a premature delivery, 
will take place. This, in fact, happens also, although less frequently, 
in secondary syphilis of the father ; the pregnancy here usually ter- 
minates normally, but the child comes into the world either with 
pemphigus syphihtica, or manifests the above delineated signs of he- 
reditary syphilis in the first six months of life. 

When the father suffers from secondary syphilis, the mother may 
remain un contaminated, and nevertheless give birth to a syphilitic 
child ; conception and delivery of such children may even be repeated 
several times without the mother becoming infected in the least. 
This often-confirmed fact is all the more remarkable, as the foetal 
blood communicates directly with the maternal, and the foetus ac- 
quires syphilitic pemphigus in utero. 

Secondary sjrphihs descends only from the mother when she be- 
comes infected with primary before or during pregnancy, and subse- 
quently manifests the secondary symptoms. When the mother only 
becomes primarily infected during the last three months of gestation, 
the offspring will remain uncontaminated. It seems very improbable 
that a healthy child could become infected from primary ulcers on the 



592 DISEASES OF CHILDREN. 

labia, with which it may come in contact during the act of deHvery. 
The children are covered with a thick layer of vemix caseosa, and 
have suifered no loss of substance on any part of the body ; in this 
case they would also have to have a primary chancre before the 
secondary eruption breaks out, a condition that is scarcely ever ob- 
served. 

There is another remarkable fact, namely, that a child, who in- 
herited its cachexia entirely from the father, the mother being sound, 
will never inoculate its own mother, while a healthy wet-nurse, who 
undertakes to suckle such a child, becomes infected as a rule. There 
results from this the therapeutically important principle that a sjrphi- 
litic child may readily enough be allowed to be suckled by its own 
mother, but never by a wet-nurse, for the latter, if she should happen 
to become inoculated, may justly hold the physician responsible. 

The manner in which a syphilitic nursling infects a healthy wet- 
nurse is not always demonstrable. The simplest manner in which the 
inoculation may take place is by the ulcers on the lips of the nursling 
coming in contact with a sore on the nipple of the breast of the wet- 
nurse. Occasionally it is observed that the breasts of the wet-nurse 
remain uninjured, and symptoms of constitutional syphilis come on 
notwithstanding. Conversely, it also happens, that a syphiHtic wet- 
nurse transmits syphilis upon a healthy child, without the nipples of 
her breasts having been diseased. There is no necessity at all to 
resort to a transmission by the milk to explain these cases. Contact 
of the child with the mouth of the wet-nurse, or with her fingers, which 
shortly before had touched syphilitic parts, seems to be the more likely 
cause. 

It is not absolutely the rule that a father who is affected with 
secondary syphilis should always beget syphihtic children. A consid- 
erable number of children remain free from all kinds of cachexia, while 
the fathers are well known to be strongly tainted. The children of a 
father are least susceptible, whose syphilis is already very inveterate, 
has left the skin and mucous membranes, and has become located as 
tertiary sj^Dhilis in the bones. 

Treatment. — Mercury acts extremely quickly and beneficially in 
syphilis of small children, and, in fact, best when applied in an ender- 
mic manner. For a number of years past I have ceased giving mer- 
curial preparations internally — calomel and mercurius solubihs Hahne- 
manni* are most frequently used in this manner. I order 3ss — 3] 
of blue mass to be actively rubbed in every day upon portions of 
sound skin, of which enough may always be found in every case. 
When the ointment is rubbed in, in the evening, a bath may be given 

* Black oxide of mercury. — Tr. 



GEXEEAL DISEASES OF THE SECRETIONS. 593 

on the next morning -without any detriment to the cure, and after that 
the inunction is repeated. 

The local ulcers are best treated by the application of small com- 
presses, wherever they can be a|)plied — dipped in chamomile tea ; the 
fissures and ulcers on the lips improve \dsibly by touching them sev- 
eral times with nitrate of silver. Baths, with corrosive sublimate, of 
which 3 i — 3 i is advised to be used in every bath, are expensive and 
dangerous to the child and its attendants, and, where the treatment is 
judiciously carried out with inunctions, may be dispensed with. The 
internal use of iodine can seldom be continued long enough in small 
children, for 'derangements of the digestion and a quicker progress of 
the marasmus are thereby frequently induced. 

The diet should be as nutritious as possible. Children who are 
nurtured at their own mothers' breasts have the best chance ,of recov- 
ering. In artificially-fed children, the chief task will be the avoidance 
of diarrhoea, w^hich may be attained by a carefully-prepared diet and 
demulcent drinks. When w^e succeed in this, the children will sur- 
mount the sj-philis. 



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INDEX 



Abdomen, Examination of the, 24. 

'• Shape of, in acute Hyclrocephalns, 

350. 
Abdominal Pains in acute Hydrocephalus, 350. 

Typhus'Fever, 18-3. 
Abscesses, reti-opharynsreal, 1:20 ; Bokai's 

Classification of, 120 ; Treatment of, 121. 
Abscesses, as a Sequel of Small-pos, 493. 
Absinth, Taste of, in Milk, 38. 
Acardia. 225. 
Acephalia, 3T5. 
Acquired Atelectasis of the Lungs, 293. 

" Hydrocephalus, 360. 

" Paraphimosis, 457. 

" Rupture of umbilical Ring, 63. 
Actual Cauteiy in Tetanus, OT. 
Acute Hydrocephalus, 339. 
Adhsesio'Linguse, 84. 
Adipose Tumors, 516. 
Affection, pneumo-gastrite-pituiteuse, 313. 
Aggregated Tubercles, 310. 
Air, Inflation of, in Asphyxia, 53. 
Albuminuria, as a Complication of Diphtheria, 

90. 
Alcoholic Drinks. Influence of, on Milk, 38. 
Amaurosis, as a Complication of Diphtheria, 

Anatomo-pathological Remarks upon the in- 
fantile Organism, 1. 

Angina Hippbcratis, 566. 

'• Larynsiia Exudatoria, 251. 

Stridula, 270. 
" Tonsillaris, 117; Symptoms of, 117: 
Treatment of, 118. 

Ankle-joint, scrofulous Inflammation of, 532; 
Treatment of, 583. 

Anterior Fontanel, Size of, 8 ; Enlargement 
of, in the Trimesters, 9, 

Antiepileptic, specific Remedies, 415. 

Anus, Examination of, 24; Malformations of 
172 ; Constriction of, 172 ; Occlusion of, 172 ; 
Treatment of, 173. 

Aphthse. 99. 

Apnoea Infantum, 270. 

Appetite, Condition of, in acute Hydrocepha- 
lus, 346. 

Arterial Telangiectasis, 242. 

Arterise Umbilicales, 2. 

Arteritis and Phlebitis umbilicales, 59. 

Arthrocace, scrofulous, 589. 

Artificial Feeding, 43. 

" Respiration, in Atelectasis Pulmo- 
num, 56. 

Ascaris Lumbricoides, 203. 

Ascites, 222; Pathology of, 222 ; Symptoms of, 
222 ; Treatment of, 223. 

Asphyxia Neonatorum, 51 ; Causes of, 52 ; 
Patliolosy of, 52; Course of, 52; Treat- 
ment of, 53. 

Assimilative Functions, Condition of, in Ty- 
phus Fever, 180. 



Asthuia Thymico Cyanoticura, 270. 
Thymicum Koppii, 275, 2S1. 

Atelectasis Pulmonura, congenital, 54; Symp- 
toms of, 55 ; Etiology of, 55 ; Treatment 
of, 55. 

Atelectasis Pulmonum, acquired, 293 ; Pathol- 
ogy of, 293 ; Symptoms of, 299 ; ProgTiosis 
of, 301 ; Treatment of, 301. 

Atresia Pupillares Congenita, 422. 
" Meatus Auditorius, 424. 
" TJrethrse, 457. 

Aura of Epilepsy, 407. 

Auricles, Absence of the, 423. 
Defect of the, 423. 

Auricula Adpressa, 424. 

" Ausbleiben," 271. 

B. 

Balanitis, 458 ; Treatment of, 459. 

Ballismus, 395. 

Bathing of Children, 49. 

Bed-sores in Typhus Fever, 189. 

Bladder, Malformations of the, 445 ; total Ab- 
sence of the, 445 ; Fissure of the, 445; Pro- 
lapsus of the, 445 ; total Splitting of the, 
445 ; partial, 445 ; J. Mliller's Explanation 
of, 447 ; Treatment of, 447 ; Earl's Appara- 
tus in, 448. 

Bladder, Cloacas of the, 448. 
Catarrh of the, 448. 

Blanchet, 99. 

Blauerhusten, 318. 

Blennorrhoeal Inflammation of the Conjunctiva 
in New-born, 73. 

Blennorrhoeal Inflammation of the Conjunc- 
tiva in difficult Dentition, JIO. 

Blennorrhcea and Ulceration of the Navel, 60 ; 
Treatment of, 60. 

Blepharospasmus, 548 ; Treatment of, 549. 

Blood-corpuscles in Milk, 34. 

Bloody Tumor of the Head, 50. 

Bodily and mental Hyrfone of Epileptics, 417. 

Bones, Gangrene of, 562; scrofulous Inflam- 
mation of, 557. 

Bothriocephalus Latus, 202. 

Brain, congenital Hernia of the, 370 ; exces- 
sive Gro\vth of, 376. 

Brain, congenital Malformations of, 375. 
" Sclerosis of the. 372; Treatment of. 372. 
" Neoplasms of the, 372 ; Carcinoma of. 

374 ; Entozote of, 374. 
" Tubercle of, 373 ; Symptoms of, 375. 

Breasts, Inflammation of the, 472. 

Bright's Disease of the Kidney, 439 ; Patholof^v 
of, 439; Frerich's Division of. 4-39 : Symp- 
toms of. 440 ; Treatment of, 443. 

Bronchial Catarrh, 282. 

'• " in diflicult dentition, 109, 

" Glands, Tuberculosis of the. 311. 

Bronchitis. 282; Pathology of. 2S0 ; Symptoms 
of, 283; Expectoration in, 2S4 : Percussion 
in, 235; Palpation in, 285; Auscultation. 



596 



IXDEX. 



in, 286 ; Eespiration in, 2S6 ; Duration of, 
286 ; Etiology of, 3ST ; as a Complication of 
Measles. of'Typlins Fever, 2ST ; of Diph- 
theria, 91 : Treatment of, 283. 

Broucho-cepbalite, 318. 

Bulimia. 127 : Treatment of, 12S. 

Burns. 51T ; Treatment of. 518. 

Butter, Amount of. iu I\lilk, accordins,- to Che- 
valier and Henry. 34. 

Butter. Amount of, in Milk, according to de- 
mon and Scherer. 34. 

Butter, Amount of, in Milk, according to Si- 
mon, 34. 

c. 

Cachexia, scrofulous, 540. 

'• tuberculous, 535. 
Calculi, renal. 443. 

" vesical, 453 ; Symptoms of, 454 ; 
Course of, 455; Treatment of, 455. 
Cancer Aquaticus. 97. 
Caput Succedaneum. 57. 
Carbonate of Soda, the Addition of. to Covr's 

Milk. 44. 
Care of Children. 48. 

'' Xavel at first Dressing. 49, 59. 
Caries, scrofulous, 559 ; C. Centralis. 560 ; C. 
Profunda, 560 ; C. Peripherica. 560 ; C. Su- 
perficialis. 530 ; C. Partialis. 560 ; C. To- 
talis. C. Necrotica, 560 : Treatment of, 560. 
Carrot-broth in artificial Feeding, 46. 
Casein in Milk, Amount of, 35. 
Catalepsis Puhnouum. 2T0. 
Cataract, congenital, 422. 
Cataracta Nuclearis, 422. 
Catarrh, 247. 

'•' convulsif, 318. 
Catarrhus, Auris Mediae. 429. 

'• Bronchialis Acutus et Chronicus, 

282. 
Cellular Tissues, Abscesses of the, in Typhus 

Fever, 189. 
Cephalsetoma, 56 : C. Supericranium, 56 ; C. 
Subaponeuroticum, 57 ; Symptoms of, 56 ; 
Etiologv of. 56 : Treatment of, 58. 
Cerebral Croup, 270. 
Chafing, 511. 

Chest, Auscultation of the, 22; Inspection of 
the, 18 ; Palpation of the. 23 ; Percussion 
of the, 19. 
Chicken-pox, 505. 
Chilblain, 518. 
Children, Care of. 23, 48. 

" General Eules for the Examination 
of. 14. 
Growth of. 7. 
" Kursing of. 28. 
" Weaning- of, 41. 
Chin-cough. 318. 
Chloroform in Tetanus, 67. 
Cholera Asiatica, 195 ; Meyer's Observation on 
the Pulse in. 197 ; Respiration. Alteration 
of the, in, 198 ; Intestinal mucous Membrane 
Dei-angements of the, in. 195 : Circulation, 
Alteration of the, iu, 197; Kidneys, Mor- 
bid alterations, etc.. Alterations o£ in, 198 ; 
Pathology of, 199; Treatment of. 199. 
Chorea Major, or Germanonim, 404 ; Svmp- 
toms of, 404 ; Prognosis of, 408 ; Treatment 
of, 406. 
Chorea Minor. 395 : Symptoms of. 395 ; Etiol- 
ogy of, 398 : Influence of the Sex in, 398 ; 
Eelation of, to Rheumatism. 399 ; Diagnosis 
and Prognosis of, 400 ; Treatment of. 400. 
Chorea Ele^ctrica of Dubini, Description of, 

400. 
Chronology of Tvphus Fever. 179. 
Cleft Palate. 80 : difficult Nursing in, 81 : ob- 
lique Position of the Teeth in. 81 ; indistinct 
Speech in, 81 ; Treatment of, 82. 



Cloacje of the Bladder, 448. 

Coagulable Fibrin in Milk, 34. 

Coated Tongue. Significance of. in Children, 

105. 
Colic, 131. 
Coloboma Iridis, 421. 

' ' of the upper Eyelid, 421. 

Colostrum Corpuscles, 34. 
Combustio, 517. 
Congelatio, 518. 

Congenital Anomalies of the Heart. 224. 
"• Anomalies of the Liver. 214. 
"■ Atelectasis of the Lungs. 54. 
" Closure of the Meatiis Urinarius, 

457. 
" Fistula of the Neck, 123. 
" Hernia of the Brain, 370. 
" Malfonnations of the Brain, 375. 
" Nsevus, 516. 
" Paraphimosis, 457. 
'• Phimosis. 456. 
" Rupture of the Cord. 02. 
Conjunctivitis Blennorrhoea Neonatcrtim. 73; 
Arlt's Division of. 73 ; Course 
and Complications of, 75; 
Causes of. 76; Prognosis of, 
77; Treatment or. 77; Pro- 
phvlactic, 78 ; Local, 78 ; Cold 
in the, 79. 
" BlennorrhcBa in Difficult Denti- 

tion. 110. 
Constipation, 138 : Causes of, 188 ; Treatment 
of. 139. 
" in acute Hydrocephalus, 345. 

" of the Wet-nurse. 41. 

Constriction of the Anus. 172. 
" Mouth. 83. 
" " Rectum, 172. 

Convulsions, 383 : Causes of, 386 : idiopathic. 
386 ; deuteropathic. 386 ; in Den- 
tition. 387 : at the breaking out 
of an actite Fever. 387 ; Cotirse , 
Termination, and Prosruosis of, 
3SS : Treatment of. 388. 
" in acute Hydrocephahts, 352. 

'■ difficult Dentition, 106. 

Coqueluche. 318. 
Corps cranulettx, 33. 
Corvza; 247 ; Etiology of, 248 ; Treatment of, 

248. 
Corvza Syphilitica, 590. 
'•Cough,"*' the, in Children, 27. 
Cotigh, nocturnal. 330. 
Cottntenance, Expressions of the, in Disease, 

15. 
Coxitis Scrofulosa, Coxarthrocace, Coxalgia, 

574. 
Cramps, 383. 
Craniotabes, 525. 

'• Relations of, to Spasmus Glot- 

tidis. 274. 
Croup, 251 ; mtico-purulent. 252 ; simply fibri- 
noits, 252 ; diphtheritic. 252 ; Symptoms of, 
253; Schlautmann's Explanation of the 
Dyspnoea in. 257 ; Occtirrence and Course 
01^ 258; Relapses in, 259: Prognosis of, 
260 ; Treatment of, 200 : Luzin sky's Method. 
263 : Bretonneau's Cauterizations in, 263 ; 
Jurin's, 264 ; Goelis's, 264 : Hufeland's, 264 ; 
Tracheotomy in. 265 ; Botichttt"s Observa- 
tion on. 265 ; Method of performing, 266 ; 
Hsemorrhage in, 266; SjTicope iii, 266; 
Goells's Remarks on. 267. 
"Cry," the. of Children, 26. 
Cryptorchidia, 462; Yon Ammon, Observa- 

"tion on, 463. 
Cyclopia, 421. 

Cutaneous Eruptions in diffictilt Dentition, 
107 ; Eczema and Impetigo, 108 ; Lichen 
and Porriso, 108 ; Urticaria, 108 ; Treat- 
ment of, 109. 



IXDEX. 



597 



Cynanclie Tonsillaris. 117. 
Trachealis, 251. 
Cystitis. 448: Patholoov of. 448; Symptoms 

of. 44S : Ti-eatment^of, 419. 
Cysts, renal. 445. 

sypliilitic, 591. 



D. 

Defectiis Aiiriculte. 423. 

Lino-ufp. S3. 
Dentition. Difficulties of. 106 ; Fever in, 106; 
Convulsions in, lOB, 3ST; Treatment of, 107. 
Deuteropathic Convulsions. 3S6. 
Diarrhcea, 135; D. Ablactatorum, 136 ; D. Sim- 
ples. 135. 
Diet of Wet-nnrscs, Influence of, on the Milk, 

37. 
Diet and Hysjiene of 'Vret-nursep, 40. 
Digestive Apparatus, Diseases of the, 80. 
Difference between Human and Cow's Milk, 

33. 
Differential Diagnosis of Measles and Scarla- 
tina. 491. 
Diphtheria of the Female Genitals, 470 ; Treat- 
ment of. 471. 
" as a Sequel of Measles, 490. 

" of the Mouth. 89 ; Symptoms of, 

89 ; Albuminuria as a Complica- 
tion of, 90 ; Bronchitis and Pneu- 
monia, 91 ; Myocarditis, 91 ; 
intestinal Catarrh. 91 ; Paralysis. 
91 ; Amaurosis. 92 ; Pathology of, 
92 ; Treatment of, 92. 
Double Limbs, 520. 
Dropsical Eflasion into tbe peritoneal Sac, 

222. 
Dropsy of the Pericardium, 240. 
Ductus Arteriosus Botalii, 9, 227. 

" A^enosus Arantii, 1. 
Dyscrasiac Pleurisv. 332. 
Dysentery. 160 ; Symptoms of, 160 ; Pathology 

of, 162 : Treatment of, 163. . 
Dyspepsia. 125 ; Bamberger's Classification 
of, 125 ; Treatment of, 130. 



Ears, Absence of the, 423. 
" Foreign Bodies in tbe, 435 ; Treatment 
of, 436. 
Earl's Apparatiis, 448. 
Eburneatio. 524. 
Eclampsia Infantum, 383. 
Ecthyma, scrofulous, 544; Treatment of, 545. 
Ectopia Alii, 174. 

Eczema, Eruption of, in difficult Dentition, 
108. 
" Impetiginodes. 543. 
" Eub:'um, 544 ; Treatment of, 545. 
Elbow-joint, sci-ofiilous Inflammation of, 583 ; 

Treatment of, 583. 
Emphysema of the Lungs, 301 ; Pathology of, 
302 ; interlobular, 302; Symptoms ol,^ 303. 
Encephalitis, 359. 

Encephalocelo, 370 ; Treatment of, 371. 
Enfants Arrieres, 417. 
English Disease, 520. 

Endocarditis, 233; Pathology of, 233; Symp- 
toms of. 234 ; Treatment of, 240. 
Endostitis, 5.55. 
Enteritis Folliculosa, 1.56 ; Pathology of, 158 ; 

Symptoms of, 157 : Treatment of, 159. 
Entero-cephalopyra, 339. 
Enthelminthes, 201. 

Eutozoje, 201 ; Symptoms of, 205 ; local, 205 ; 
general and reflex Phenomena of, 
200; Diagnosis of, 207; Treatment 
of, 207. 
" of the Brain, 374. 



Enuresis, 4.50 ; Treatment of, 451. 

Epicanthus, 420. 

Epilepsy. 407 ; Symptoms of, 407 ; Course of. 

410; "Termination of, 410 ; Causes of, 410; 

Hereditary Nature of, 411 ; x>ost-mor^em 

Appearances in, 412; Diagnosis of, 413; 

Treatment of. 413 ; prophylactic, 414 ; 

Causale. 414; of the Paroxysm, 415; with 

Antiepileptic Specifics, 415; general bodily 

and mental Hygiene in, 417. 
Epispadia, 4,58. 
Epistaxis, 245; Etiology, 245; Symptoms of, 

246 ; Treatment, S46. 
Epithelium-cells in Milk, 34. 
Erectile Tumors, 242; Pathology of, 243; 

Treatment of, 243. 
Erysipelas, 510; Causes of, 510; Treatment 

of. 511. 
Erythema Neonatorum, 509 ; Symptoms, 509 ; 

Etiology, 510 ; Treatment of, 510. 
Eselhusten, 318. 
Essential Paralysis, 391. 
Ethereal Oils, the Odor of, in Milk, .33. 
Expectoration in Pulmonary Tuberculosis, 

325. 
Extremities, Kacbitis of the, 530. 

Position of, at first Dressing, 
49. 
Eye, Scrofulous Affection of the, 547, 548. 
" Diseases of the, as a Complacation of 
Small-pox, 498. 
Eyeball, Malformations of the, 421. 



Face, Color of the. in Tuberculosis, 536. 

Facial Erysipelas as a Complication of Typhus 
Fever, 189. 
" Paralysis, 390. * 

Falling Sickness, 407. 

Fallsucht, 497. 

Fames Canina. 127. 

Fat, the, of Milk, 34. 

Fat Scabies, 514. 

Fatty Liver, 211. 

Febris Hydrocephalica, 339. 
" Intermittens, 210. 

Feeding, artificial, 43. 

'• of the Child in the second Year. 43, 

Female Genitals, Gangrene of the, 471 ; Treat- 
ment of, 471. 
" '" Diphtheria of tlie, 470; 

Treatment of, 471. 
" " Malformations of the, 4S6. 

Fette Kratze, 514. 

Fibrine, coagulable, in Milk, 34. 

First Dressing of the New-born, 49. 

Fissura Ani, 168 ; Treatment of, 169. 

Fistula Coli congenita, 123 ; Treatment of, 124. 

Fits, 407. 

Flatulence, 1.31 ; Symptoms of, 132 ; Treat- 
ment of, 133. 

Fluctuation, Method of ascertaining, 222. 

Fluor Albus, 408. 

Pkix, 160. 

Fontanel, Enlargement of the, 8 ; Elsiisser's 
Method of measuring the, 8. 
" Average Size of the, in the Trimes- 
ters, 9. 

Foramen ovale, 2. 

Foreign Bodies in the Ear, 435 ; Treatment of, 
436. 

Foreign Bodies in the Nose. 250 ; Treatment 
of,'^250. 

Forficula Auricula, 435. 

Frost-bite, 518 ; Treatment of, 519. 

Functional Distirrbauces in acquired Hydro- 
cephalus, 308. 

Fungus Articuli, 569. 

" IJmbilicalis. 61 ; Treatment of, 01. 

Furunculosis, 512 ; Treatment of, 512. 



598 



IXDEX. 



Furunculosls, as a Sequel of Small-pox, 498. 
'• in Typhus Fever, 189. 

G. 

Galactometer. Method of using the, 35. 

GauoTfena Pulmonum, 307 ; Pathology of, 307; 
diffused, 307 ; circumscribed, 308 ; Symp- 
toms of. 309 ; Treatment of, 309. 

Garlic, Odor of, in Milk, 38. 

Gastric mucous Membranes, hsemorrhagic 
ErosioDS of the, 144. 

Gastric mucous Membranes, catarrhalic In- 
flammation of the, 140. 

Gastritis Catarrhalis, 140 ; Symptoms of, 140 ; 
Treatment of, 141. 

Gastritis FoUiculosa, 144. 

Gastromalacia, 145. 

Gefass Nabel, 64. 

Genitals, Examination of the, 25. 

Glandular Internal Organs, syphilitic Affec- 
tions of the, 590. 

Gonalgia. 580. 

Gonarthrocace, 580. 

n. 

Hsemoptoic pulmonary Infarction, 306 ; Pa- 
thology of, 306 ; Symptoms of, 307. 

Htemoptysis. .305 ; Yarieties of, 305 ; in tuber- 
culous Children. 306 ; Treatment of, 306. 

Haemorrhage from the Lungs, 305. 

of the iSTavel, 61 ; Treatment of, 
62. 
" in Tracheotomy, 266. 

Ha^morrhagia Pulmonum, 305. 

'• Yaginse, 471 ; Treatment of, 472. 

Hard Cataract, 422. 

Hare-Lip, 80 ; difficult nursing in, 81 ; Malpo- 
'sition of the Teeth in, 81 ; indistinct Speech 
in, 81 ; Treatment of, 82. 

Headache in acute Hydrocephalus, 349. 

Head and nervous Symptoms in Typhus 
Fever, 189. 

Hearing. Condition of the, in acute Hydro- 
cephalus, 354. 

Heart, congenital Anomalies of the, 224 ; Ab- 
sence of the, 225 : abnormal Situation of 
the, 225 ; abnormal Shape and Size of the. 
225 ; abnoi'mal Formation of individual 
Parts of, 228; Symptoms of, 228; Treat- 
ment of, 231. 

Hectic Fever in Tuberculosis, 536. 

Helminthiasis, 201. 

Henle's Milk Test, .30. 

Hepar Adiposum, 211. 

Hernia Inguinalis. 166 ; Yarieties and Compli- 
cations of, 167 ; Treatment of, 168. 

Hernia Umbilicalis, 62 ; Treatment of, 63. 

Hiatus Spinalis Congenitus, 380. 

Hip-joint, scrofulous Inflammation of the, 574; 
^Treatment of, 578. 

'■'■ tiottencot's Apron," 476. 

Hydrocele, 463 ; Yarieties of, 4G4 ; Treatment 
of, 466. 

Hydrocephalic Cry, 351. 

Hydrocephalic Exudation, Composition of the, 
341. 

Hj'drocephaloid Disease. 363 ; Symptoms of, 
363 ; post-mortem appearances in, 364 ; 
Treatment of, 365. 

Hydrocephalus, acute, internal, 339 ; Pathol- 
" oo'v of. .340 : C. Schmidt's chemical Analvsis 
of tlie Ettusion in, 341 ; Symptoms of, 342 ; 
Bouchufs stadial Division of, 342; Yomit- 
ing m, 345; Constipation in, 345; State of 
the Appetite in. 346; of the Pulse in, 347; 
respiratory Disturbances in, 348 : Condi- 
tion of the Skin in, 349 ; meningitic Spots 
in. 349: Headache in, 349; "abdominal 
Pains in. 350 : Shape of the Abdomen in, 
350 ; psychical Disturbances in, 351 ; hj'- 



drocephalic Cry in, 351 ; general and local 
Convulsions in, 352 ; state of the Pupils in, 
353; Brachet's Observations on. 353; of the 
Hearing in, 354; Termination and Prog- 
nosis of, 355 ; Treatment of, 356. 

Hydrocephalus, chronic, 365 ; Pathology of, 
365 ; acquired, 366 ; Causes of, 366 ; Sjonp- 
toms of, 367 ; functional Disturhances in, 
368 ; Course of, 369 : Treatment of, 370. 

Hydrophlogosis Yentriculorum Cerebri, 339. 

Hydropericardium, 240 ; Pathology of, 240; 
Symptoms of, 241 ; Treatment of, 241. 

Hydrorrhachia. 380. 

Hydrothorax, 337 ; Causes of. 338 ; Symptoms 
of, 3-38; Prognosis of, 389; Treatment of, 
339. 

Hypertrophy Tonsillarum, 119 ; Treatment 
of, 129. 
" and Prolapse of the Tongue, 84. 

Hypospadia, 457. 

I. 

Icterus ISTeonatorum, 72 ; Treatment of, 72. 
Idiopathic Convulsions, 386. 
Idiotism, 417. 

Imbecility. 417 ; Symptoms of, 418 ; Le Paul- 
mier's Division of, 419 ; Prognosis of, 419 ; 
Treatment of. 418, 420. 
Impetigo, Eruption of, in difficult Dentition. 
108. 
" scrofulous, 544 ; Treatment of, 54.3. 
Incontinentia Urinse, 450. 
Induratio Telse Cellulosse, 67. 
Infarctus Eenalis, 5, 437. 
Influenza, 287. 
Inguinal Hernia, 166. 
Innervation, Influence of. on the Milk, .36. 
Intermittent Fever, 216 ; Etiology of, 216 ; 
Symptoms of, 216 ; Pathology of, 218 ; 
Treatment of, 218. 
Insolatio. 362. 

Intestinal Catarrh, 150 ; Causes of, 151 ; Symp- 
toms of, 152 ; Treatment 
of, 154. 
" "• in difficult Dentition, 109. 

'' " as a Complication of Diph- 

theria, 91. 
" " as a Complication of Small- 

pox, 498. 
" " as a Sequel of Measles, 4S0. 

" Haemorrhage, 70. 
" " '" in Typhus Fever, 184. 

" Evacuations " " " 182. 

Navel, 63. 
" mucous Membrane, Disturbances 
of, in Cholera, 195. 
Intertrigo, 511 ; Treatment of, 512. 
Introductory Remarks, 1. 
IntussuscepUon. 163 ; Pathology of, 163 ; 
Svmptoms of, 185 ; Treatment of, 165 ; 
Plfeufer's, 166. 
Invagination, 163. 

Involuntary Movements of the Muscles, .395. 
Iodide of Potassium, to detect, in Milk, 38. 
Trideremia, 421. 
Iridoschisma. 421. 
Irritatio Cerebri, 363. 
Ischuria, 452 ; Treatment of, 453. 



Jaundice, 72. 

Joints, Inflammation of the, as a Sequel of 
Small-pox, 498. 
" scrofulous Inflammation of the. 568; 
Symptoms of, 570 ; Recovery in, 
with good Use of the. 5T1 ; with im- 
paired Function of, 572 ; with Dis- 
location, 572 ; Treatment of, 572 ; 
Jobert's, 573 ; Rust's, 573 ; Priesnitz's 
Method of, 573. 



IXDEX. 



599 



K. 

Keratitis Scrofulosa. 54T. 
Kidneys, Malformatious of tlie, 437; simple, 
437 : single, 437. 
Affections of the. 439. 
Morbid Alterations of, in Cholera 
_ Asiatica, 19S. 

i^uee-joir.t, scrofnloiis Inflammation of the, 
5S9 : Symptoms of, 580 : false Anchylosis 
in. 581; true Anchylosis in, 581; Treat- 
ment of. 581. 
Kyphosis Paralytica, 564. 
Scohatica, 505. 



Laliium Leporinum, SO. 
Lanuj^o, 6. 

Larynx, Abscesses of the, in Tvphus Fever, 
186. 
X^urosis of the. 270. 
Larynjrea Tracheitis Exudativa, 251. 
Laryngitis Catarrhalis, 2G7. 

" et Tracheitis Maligna, 251. 
'• as a Complication of Small-pox, 
498. 
Laryngismus Stridulus, 270. 
Laryngo-spasmus Infantilis, 270. 
Leucorrhcsa, 468; Causes of, 468; Treatment 

of. 469. 
Lichen, Eruption of, in difficult Dentition, 

108. 
Liebig's Soup, 45. 
Lithiasis, 453; Symptoms of, 454; Course of, 

455 ; Treatment of, 455. 
Liver, average "Weight of the, 209 ; Frerich's 
Estimate, 209 ; Portal and MeckeFs, 
209. 
'■' congenital Auoitialies of the, 214. 
" •' Transpositions of the, 2ft:. 

" fatt\-, 211; Pathology of, 212; Symp- 
toms and Treatment of, 21.3. 
" syphilitic Inflammation of the, 210 ; 
Pathology of, 210 ; Symptoms - and 
Treatment of, 211. 
Lobar Pneumonia, 289. 

•' in Typhus Fever, 186. 

Lobular Pneumonia, 289. 
Lungs, Carcinoma of the, 316 ; Symptoms of, 
317 ; Treatment of, 318. 
'' Gangrene of the, 307 ; Pathology of, 
•307; diff'used, 307; circumscribed, 
308 : Symptoms of, 309 ; Treatment 
of, 309. 
" Inflammation of the, 289. 
" Tuberculosis of the, 309 ; Pathology 
of, 309; Varieties of, 309; Symp- 
toms of, 313 ; Respiration, Condi- 
tion of, in, 314; Expectoration in, 
.315. 
Lupus, 544 ; L. Exfoliatus, .544 ; L. Exulcerans, 
544 ; L. Serpiginosus, 545 ; L. Tuberosus, 
544; Treatment of, 545. 
Luxatio Spontanea, 574. 
Lymphatic Glands, scrofulous Affections of 
the, 551 ; Pathology of. 551 ; simple Hyper- 
trophy of the, .551 ; Tuberculosis of, 551 ; 
Treatment of, 553. 

M. 

iMale Genitals, Malformations of the, 456. 

Malum Potii, 564. 

Mastitis Neonatorum, 472 ; Treatment of, 473. 

Masturbatio, 460. 

Measles, 484; normal, 485; the Stage of Pro- 
dromata in, 485 ; of Eruption, 485 ; of Flores- 
cence, 486 ; of Desquamation, 486 ; Varia- 
tions of, 487 ; Modiflcation of the Exanthema 



in. 487; Participation of tlie mucous Mem- 
brane in, 487; Conjunctivitis in, 487; nasal 
Catarrh in. 488 ; Inflammation of the Glottis 
in, 488 ; Diphtheritis and Coryza in, 488 :^ 
lobar and lobular Pneumonia in, 488; in- 
testinal Catarrh in, 488; Character of the 
Fever in, 483 ; erethitic Form of, 488 ; syno- 
clial Form of, 488 ; torpid Form of, 489 ; 
septic or putrid Form of, 489 ; Sequelae of, 
489 ; Tuberculosis, 489 ; Otorrhosa, 490 ; 
Diphtheria, 490 ; intestinal Catarrh, 490 ; 
Noma, 490 ; Diagnosis of, 490 ; differential 
Diagnosis of Measles and Scarlet Fever, 
491 ; Prognosis of, 492 ; Etiology of, 492 ; 
Treatment of regular, 492; of irregular, 
493. 
Meatus Auditorius, Abscesses in the, 428. 

Closure of the, 424 ; Treat- 
ment of, 425. 
" " simple Inflammation of 

the, 425. 
" Urinarius, Closure of the, 457. 
Meconium, 4; Foerster's Analysis of the, 4. 
Mediastinum Anticum, Carcinoma of. Symp- 
toms of, 317 ; Treatment of, 318. 
Medicines, Eftects of, on the Milk, 38. 
Mehlmund, 99. 
Meltena Neonatorum, 70 ; Treatment of, 71 ; 

Rilliet's, 71. 
Melansemia, 218. 
Membranous Navel, 64. 

"• Quinsy, 251. 

Meningeal Tuberculosis, 339. 
Meningitis Simplex, 359 ; Etiology of, 359 ; 
Pathology of, 359 ; Symptoms of, 360 ; Treat- 
ment of, 361. 
Meningitis Purulenta, .359. 

"• as a Complication of Small-pox, 

498. 
Meningitic Spots in acute Hydrocephalus, 349. 
Menstruating Wet-nurses, Danger from, 41. 
Mesenteric 'Glands, morbid Alterations of, 

224. 
Metastases in Scarlet Fever, 481. 
" Typhus Fever, 190. 
Metastatic Parotitis, 115. 
Microstoma, 83 ; Treatment of, 83. 
Microcephalia, ,376. 
Mictio Involuntaria, 450. 
Middle Ear, Inflammation of the, 429. 
Miliaiy Tuberculosis, 309. 
Miliaries in Typhus Fever, 188. 
Milk, Blood-Corpuscles in, 34, 
" Butter in, 34. 
" Casein in, 35. 
" coagulable Fibrin in, 34. 
" Corps Granuleux, 33. 
" Cow's, 43. 
" Epithelium-Cells in, 34. 
'■• insoluble Salts in, 35. 
" mucous Corpuscles in, 34. 
" microscopic Examination of the, 3.3. 
" soluble Salts in, .35. 
" specific Gravity of, 32. 
" Sugar of Milk in, 34. 
" Woman's, 32. 
•' Test, Henle's, ,33. 
" " Mitscherlich's, ,33. 
" " ordinary, 39. 
Mitscherlich's Milk Test. 33. 
Modified Scarlet Fever. 478. 

" Small-pox, 505. 
Moist Girdle, Use of the, in Pneumonia, 297. 
Monophthalmia, 421. 
Morbilli, 484. 
Morbus Briahtii, 430. 

Cerebralis ^Vliyttii, 339. 
" Coxarum, 574. 
" Sacer, 407. 
" Strano-nlatorius. 251. 
Mortificatio Pulmonum, 307. 



600 



IXDEX. 



Mothers' Marks, 510. 

Mouth, Constriction of the. S3. 

" Diphtheria of the, i39, 

" Examination of the, 25. 

" mncoLis Membrane of the, catarrhalic 
Inflammation of, 87. 
Mucous corpuscles iu Milk, 34. 

" Membranes, scrofulous Affections of 
the, 546. 
Mucous Membranes, syphilitic Affections of 

the, 589. 
Muguet. 99. 
Miiller, Canals of, 486. 
Mundsohr, 99. 
Muscles and Bones, syphilitic Affections of, 

590. 
Muscular Jactitation, 395. 
Myocarditis as a Complication of Diphtheria, 

91. 



X. 

Nsevus Lipomatodes, 516 ; Treatment of, 517. 

" Yasculosus, 242. 
Nasal Cavities, Exploration of the, 245 ; Win- 
trich's Method, 245. 
" Mucous Membrane, syphilitic Affec- 
tions of the, 589. 
Navel, Blennorrhoea and Ulceration of the, 60 ; 
Treatment of, 60. 
Care of the, 49, 59. 
'•' Diseases of the, 58. 
" Gangrene of the, 60 ; Treatment of, 60. 
" Haemorrhage of the, 61 ; Treatment of, 

62. 
" Intestinal, 63. 
" Membranous. 63. 
" Eupture of the, 62. 
" Vascular, 63. 
Necrosis, scrofulous, 562 ; centrale, 562 : 
supei-ficial, 583 ; total, 503 ; Symp- 
toms of, 583 : Prosiiosis of, 563 
Treatment of. 564. 
" as a Sequel of Small-pox, 49So 
Nephritis, 439. 

" as a Complication of Diphtheria, 90. 

Nocturnal Coush. periodic, 330; Treatment 
of,"330. 
" Micturition in Bed. 450. 
Noma, 97 ; Symptoms of, 98 ; Treatment of, 
99. 
" as a Sequel of Measles, 490. 
Nose, adventitious Growths in the, 248. 
" Bleedingof the, 245. 
" foreign "Bodies in the, 250; Treatment 

of, 250. 
" scrofulous Aft'ection of the, 548. 
Normal Navel, Treatment of the. 59. 
Nursing and Care of Children, 28. 
Nutrition, artificial, 43. 
Nystagmus Ctecillatorius and Eotatorius, 422. 



0. 

Obstipation, 138. 

Obstructio Alvi. 138. 

(Edema Compactum, 67. 
" Neonatorum, 67. 

" Pulmonum, 303; Patholosy of, 303; 
Symptoms of, .304; Treatment of, 
305. 
" of the Liines in Typhus Fever, 186. 

CEsophagitis. 122rSymptoms of, 122; Treat- 
ment of, 123. 

Olenarthrocace, 583 : Treatment of, 583. 

Onanism. 460 ; Kraft's case of, 461 ; Causes of, 
461 ; Treatment of, 462. 

Onychia, syphilitic, 590. 

Ordinaiy Milk Test, .89. 

Organ of Hearing, Malformation of, 423. 



Organs of Sense, scrofulous Affections of the, 
546. 
'■ " Disturbances of, in acute 

Hydrocephalus, .353. 
Osteomyelitis, 555; Pathology of, 555; Treat- 
ment of, 557. 
Ostitis, scrofulous, 55'7; Osteoporosis, 557; 
Eesolution in, 558; Suppuration in, 558; 
Caries as a Eesult of, 559: Necrosis as a 
Eesult of, 559 ; Treatment of, 559. 
Otitis Externa, 425 ; catarrhal, 425 ; erythemat- 
ous, 426 : Symptoms of, 425; 
Etiology of, 427 ; Treatment 
of, 427. 
" " Phlegmonosa, 428; Treatment 

of, 429. 
" Interna, 429 ; Diagnosis of, 430 ; Ter- 
mination of, 430 ; Treat- 
ment of, 430. 
'• " the real, 431 ; Symptoms of, 

4.81 ; Terminations of, 432 ; 
Causes of, 433 ; Treatment 
of, 433. 
Otorrhcea, as a Complication of Small-pox, 
498. 
" as a Sequel of Measles, 490. 
Oxyuris Vermicularis, 204. 
Ozsena, simple, 546; scrofulous, 546; Treat- 
ment of, 547. 



Palatum Fissum, 80. 

Paraphimosis, acquired, 459 ; Treatment of, 
400. 
" congenital, 457. 

Paralysis, 390 ; essential. 391 ; facial, 390 ; 
Symptoms of, 391 ; Causes of, 393 ; 
Treatmenf of, 394. 
' " as a Complication of Diphtheria, 91. 
Glottidis, 278; Symptoms of, 278; 
Duration of, 279 ; Treatment of, 
279. 
Parotid, Hypertrophy of the, benign, 116 ; 

Treatment of, 116. 
Parotid, Hypertrophy of the, malignant, 116 ; 

Treatment of, 116. 
Parotitis, idiopathic, 111 : Symptoms of, 112 ; 
Course and Termination of, 113 ; 
Pathology of, 113 ; Therapeutics 
of, 114. ^ 
" metastatic, 115 ; Treatment of, 115. 
'• secondary, 114 ; Treatment of. 114. 
" as a Complication of Typhus Fever, 
181. 
Pelvis, Eachitis of the, 529. 
Pemphigus Syphilitica. 587. 
Penis, Malformation of the. 456. 
Pericarditis, 236; Pathology of. 237; Symp- 
toms of, 238 ; Treatment of, 240. 
Pericardium, Dropsy of the, 240; Pathology 
of. 240 ; Symptoms of, 241 ; Treatment of, 
241. 
Periodic nocturnal Cough, 330 ; Treatment of, 

330. 
Periostitis of the middle Ear, 431. 

" scrofulous, 553 ; Pathology of, 554 ; 

Hypertrophy -as a Eesiilt of, 5.54; 
Eesolution iu, 554 ; Suppuration 
in, 554 : Prognosis of, 555 ; Treat- 
ment of. 555. 
Peritonitis, acute, 219 ; Causes of, 220 ; Symp- 
toms of, 220 ; Pathology of, 221 ; 
Treatment of, 221. 
" chronic, 219. 

Pertussis, 318. 

Perspiration in Typhus Fever, 188. 
Petechia in Typhus Fever, 189. 
Pharyngo-laryngitis pseudomembrauacea, 251. 
Phimosis, congenital, 450 ; Treatment of, 450. 



IXDEX. 



601 



Phlebitis and Arteritis Umbilicalis. 59 ; Treat- 
ment of. 60. 
Phreno-glottismns. 2T0. 
Physiological Dentition, Irregularities of, 13. 
Pigmentary Xtevi. 516. 
Pityriasis Lingnce, 105. 

Pleurisy, 331 ; Pathology of, 331 ; Complica- 
tions of, 335: Symptoms of, 232; 
Treatment of, 336. 
'' clyscrasiac, 332. 
'■ purely inflammatory. 331. 
'■ as a Complication of Small-pox, 498. 
Pleuritis. 331. 
Pneumonia, 2S9 ; Pathology of, 290. 

'' lobar, 290 ; Infiltration purulent, 

in. 291. 
- " lobular, 291 ; Symptoms of, 292 ; 

Percussion in. 293; Ausculta- 
tioo in, 293: Palpation in. 293; 
Course of, 294; Treatment of, 
295. 
"• as a Complication of Diphtheria, 

91. 
Podarthrocace. 582. 
Polyphagia, 127. 

Polj-pi, nasal. 248 ; Etiology of, ^49 ; Symp- 
toms of, 249 ; Treatment of. 250. 
rectal, 1G9 ; Treatment of, 170. 
Pomphi, 107. 
Porrigo, 548. 

Eruption of, in difficult Dentition, 
108. 
Position of Extremities at first Dressing, 49. 
Practical Examination of Milk, 39. 
Pregnancies. Recurrence of, in Lactation, 39. 
Prepuce, Inflammation of the, 45S. 
Prolapsus Aui. 170 : Causes of. 171 ; Prognosis 
of, 171 : Treatment of, 171. 
" Lingute, 84 ; Treatment of. 84. 

Pseudo-croup. 267 : Symptoms of, 268 ; Dura- 
tion of, 263 : Treatment of. 269. 
Psychical Disturbances in acute Hydrocepha- 
lus, 351. 
Pulmonary Emphysema, 301. 
Pulse. Examination of the, 17. 

" State of the, in acute Hydroceohalus, 
347. 
Pupils, State of the, in acute Hydrocephalus, 

Putrid sore Mouth, 93. 

Pyaemia as a Complication of Small-pox, 498. 



Quaddeln, lOT. 



R. 



Eachitis, 520; Pathology of, 520; Symptoms 
of, 525. 
" of the Extremities. 530 ; of the Pel- 
vis, 529 ; of the Thorax, 527 ; Re- 
lation of, to Scrofala and Tuber- 
culosis, 531 ; Prognosis of, 532 ; 
Etiology of, 532 ; Treatment of, 
533. ^ 
Ranula, 85 : Prognosis of. 87 ; Treatment of, 87. 
Rectum. Malformation of the, 172 ; Treatment 

of, 173. 
Relapses in Typhus Fever, 190. 
Relation of Rachitis to Scrofula and Tuber- 
culosis, 531. 
Ren Unguiformis, 437. 
"Reprise" in Whooping-Cough, 319. 
Respiration and Circulation, 1. 

"'• Disturbance of the, in Cholera, 

198. 
" Disturbance of the, in acute Hy- 

drocephalus, 348. 
" Condition of the, in pulmouaiy 

Tuberculosis, 314. 



Retention of Urine. 452. 

Retropharyngeal Abscesses, 120 ; Prognosis 

of, 121 ;" Treatment of, 121. 
Rhagades, syphilitic, 588. 
Rheumatisni, acute, 232; Symptoms of, 232; 

Treatment of, 240. 
Rhinitis, 247. 
Rickets, 520. 
Roseola Syphilitica. 580. 

Typhosa, 187. 
RC)theln. 494. 
Round Worm, 203. 
Rubeola, 494 ; Kostlein's Description of, 495 ; 

Symptoms of, 495 ; Treatment of, 495. 
Rupia, scrofulous, 544 ; Treatment of, 545. 
Rupture of the umbilical Ring, 63. 



R. 



Salts, insoluble in Milk, 35. 
" soluble " " 36. 
Scabies, 513 ; Treatment of, 514. 
Scarlatina, 474; s. Angina, 477; s. Exanthema, 
478. 
" Legitimata, 474. 
" Levigata, 478. 
"• Papulosa, 478. 
" Variegata, 478. 
Scarlet Fever, normal, 474; Stage of Eruption 
and Florescence, 475 ; of 
Desquamation, 476 ; of Incu- 
bation and Premonition, 474. 
" Participation of the mucous 

Membrane in, 478. 
" erethitic Form of, 479; septic, 

480; synochal, 480; torpid 
or nervous, 480. 
" anomalous Localizations of, 

480. 
" Intensity of the general System 

in, 479. 
" Modification of Form of the 

Exanthema in, 477. 
" Metastases in, 481. 

Sequelce of, 481; Etiology of, 481 ; 
Treatment of, 482 ; Schnee- 
mann's method of, 482. 
SchnuUer, 47. 
Scleroma, 67 ; Symptoms of, 67 ; Pathology of, 

69 ; Causes of, 70 ; Treatment of, 70. 
Scrotum, Gangrene of the, as a Complication 

of Small-pox, 493. 
Scelotyrbe, 395. 
Scoliosis, 564. 
Scorbutiis, 96 ; Symptoms of, 96 ; Treatment 

of, 97. 
Scrofula, 534; Connection of, with Tuberculo- 
sis, 535. 
Scrofulous Cachexia, 540 ; general Treatment 

of, 584. 
Seborrhcea Capillitii, 6. 
Secretions, 4. 
Selmenflecke, 237. 
Sexual Functions, Influence of, on the Milk, 

38. 
Simple (Edema, 442. 

Skin, Condition of the, in acute Hydrocepha- 
lus, 349. 
" " of the, in Typhus Fever, 187. 

" Color of the. in Tuberculosis. .537. 
" scrofulous Aftections o-f the, 542. 
Skull, Measurements of the, 7. 

'• Rachitis of the, 525. 
Small-pox, 496. 

" Modified, 507. 
Soor. 99. 

Soda Bicarb., Use of, in Milk, 44. 
Spasms, 383. 

Spasmus Glottidis, 278 ; Symptoms of, 2T1 ; 
general Convulsions in, 271 ; Duration, 
Course, and Prognosis of. 272 ; Causes of, 



602 



IXDEX. 



273 ; general, 2T4 ; Influence of Age on, 2T4 ; 
hereditary Character of, 274 ; Connection 
between Craniotabes and, 274; Pathology 
of. 275 ; Treatment of, 276 ; prophylactic, 
278 ; of the Attack, 276 : of the Cause, 277 ; 
Scariticatiou of the Gums in, 277. 
Spilus, 516. 

Spina Bifida, 380 ; Pathology of. 380 ; Symp- 
toms of, 381 ; Treatment of, 
382 ; Chassaignac's 382. 
" Yentosa, 556. 
Spinal Meningitis and Myelitis, 376 ; Pathol- 
ogy of, 377 ; Symptoms of, 378 ; Treatment 
of, 380. 
Spleen, Enlargement of, in Typhus Fever, 184. 

Hypertrophy of, 215. 
Spondylarthrocace, 564. 

" Cervicalis, 566. 

" Lumbalis, 567. 

" Thoracica, 566. 

Treatment of, 568. 
Spring-yrorm, 204. 
Sprue, 99. 
Sterno-cleido-mastoideus Muscles, Sclerosis 

of the, 124 ; Treatment of, 124. 
Stomacace, 93 ; Causes of, 94 ; Treatment of, 95. 
Stomach, catarrhalic Inflammation of the, 140 ; 
Symptoms of, 140 ; Treatment of, 
141. 
" perforating Ulcer of the, 144. 
" Softening of the, 145. 

" " black, 146. 
" " " " gelatiniform, 146. 

" toxic Inflammation of the, 141 ; 
Symptoms and Pathology of, 142; 
Treatment of, 143. 
Stomatitis Catarrhalis, 87 ; Ulcerosa, 88 ; 
Treatment of, 88. 
" Cremosa, 99. 

Stomato Necrosis, 97. 
Stone-pox. 507. 
Struma, 279. 

Cystica, 280. 
" Lymphatica. 280. 
Treatment of, 280. 
Subcutaneous Cellular Tissue, syphilitic Af- 
fection of the, 589. 
Sucking-Bottles, 47. 
Sudamina Rubra, 531. 
Sugar-Teat. 47. 

'• ofMilkinMilk, 34. 
Suffocatio Stridula. 251. 270. 
Sunstroke, 362; Symptoms of, 362; Treat- 
ment of, 363. 
Swine-pox, .507. 
Syncope of the jSTew-bom, 51. 
" " in Tracheotomy, 266. 
Syphilis, hereditary. 586 ; Course and Termi- 
nation, 591 ; Etiology of, 591 ; Treatment of. 



T. 



Tabes Mesenterica, 156; Pathology of, 156; 

Symptoms of, 157 ; Treatment of, 159. 
Taches Lenticalaris, 187. 

" Meningitique, 349. 
Tffinise Solium, 202. 
Teeth. Eruption of the, 11. 
Tetanus Apnoecus, 270. 

" Neonatorum, 64; Symptoms of, 64; 
Causes of, 65; Prognosis of, 66; 
Treatment of, 66. 
Thighs, Examination of the inner Surfaces of 

the, 3. 
Thorax, Eachitis of the, 529. 
Thrombi in the Sinuses of the Dura Mater, 

244. 
Thrush, 99; Symptoms of, 100; Causes of, 

104 ; Treatment of, 104. 
Thymise, the Odor of the, in Milk, 33. 



Thymus Gland, 231 ; Carcinoma of the, 281 ; 
Tuberculosis of the, 281 _; syphilitic Ab- 
scesses of the, .590; syphilitic Cysts of the, 
591. 
The Time that has elapsed since Confinement, 

Influence of. on Milk, 37. 
Tinea Capitis, 543. 

Tongue, abnormal Adhesions of the, 84. 
'■ Examination of the, 11. 
" Hypertrophy and Prolapse of the, 

84 ; Treatment of, 84. 
" Imperfect Development of the, 83. 
Tonsillitis, 117. 
Tonsils, Hypertrophy of the, 119 ; Treatment 

of, 120. 
Tracheotomy, 265 ; Method of Performing, 
266 ; Hagmorrhage from, 266 ; Syncope in, 
266. 
Tremors of the Head, 383. 
Tricocephalus Dispar, 204. 
Trimesters, 9. 

Trismus of the New-born. 64. 
Tubercles, aggregated, 310. 
Cerebral, 373. 
" Miliary, 309. 

Infiltration, 310. 
Tuberculosis of the bronchial Glands, 311 ; 
of the Lungs, 309 ; Pathology 
of, 309 ; Symptoms of, 313 ; 
State of the Eespiration in, 
314 ; Cough in, 313 ; Expecto- 
ration in. '315 ; Course of, 316. 
" ofthe Brain, 339. 

" Connection of, with Scrofula, 

534. 
" of the Ear, 433. 

" '' Kidney, 444. 

" '• Mesenteric Glands, 157. 

" '' Vertebras, 564. 

" as a Sequel of Measles, 489. 

Tuberculous Cachexia, 535 ; general Symp- 
toms of, 536 ; Color ofthe Face in, 536 ; hectic 
Fever in, 536 : Condition of the Skin in, 
537 ; general ffidema in, 537; Prognosis of, 
538; Etiology of, 538; general Treatment 
of, 584. 
Tumor Albus Articuli Pedis, 582. 

'' Genu, 580. 
Tussis, 318. 

" Convulsiya, 318. 
" Sufi"ocativa, 318. 
Typhus Fever, 175 ; Pathology of, 176 j Symp- 
toms of, 178; abdominal Pains in, 172; 
Abscesses of the cellular Tissue in, 189 ; 
Bed-sores in. 189 ; Chronology of. 179 ; 
facial Erysipelas in, 189 ; Furuuculosis in, 
189 ; head and nervous Symptoms in, 179 ; 
Eruption in, 187; intestinal Evacuations 
in, 182 ; larjmgeal Abscesses in, 186 ; lob- 
ular Pneumonia in, 186; Metastases in, 
190; Miliaries in, 188; (Edema of the 
Lun<^s in, 186 ; Parotitis in. 181 ; Perspira- 
tion in, 188 ; Petechise in, 189 ; Relapses in, 
190; Roseola Typhosa, 187; Taches Len- 
ticularis, 187 ; Treatment of, 191. 

U. 

Ulceratio Ossis, 559. 

Ulcus Ventriculi Rotundum slve Perforans, 

144. 
Umbilical Arteries, 2. 

" Ring, acquired Rupture of the, 63; 

Treatment of, 64. 
" Stump, Ulceration ofthe, 61 ; Treat- 

ment of, 61. 
" Vessels, Inflammation of the, 59; 
Treatment of, 60. 
Urethra, anomalous Openings ofthe, 457. 
Uric- Acid Infarction ofthe New-born, 5, 437. 
Urticaria, Eruption of, in difficult Dentition, 
107. 



INDEX. 



603 



uterus Biconiis, 467. 
Unicornis, 467. 



Y. 

Vaccinia Vesicles. 499. 
Vaccination, 409. 

Method of performing. 509. 
Varicellce. 507 ; Svruptoms of, 507 f Treatment 
of. 509. 
'• Acuminata, 508. 
" Couiformis, 508. 
'• Lenticularis, 508. 
Variola. 496 ; Symptoms of, 496 : Stage of In- 
cubation and Prodromata, 496; of Erup- 
tion and Florescence. 496 ; of Desiccation, 
497; Febris Secondaria, 497; Complica- 
tions of. 498 : Etiolosv of, 498 ; Mortality 
in. 498; Sequela; of,'' 498 ; Treatment of, 
498. 
Variolte Cohterentes, 497. 
" Conflueutes, 497. 
•' Corymbosse. 497. 
" Cruentte. 497. 

Crvstallinise. 497. 
Depressse, 497. 
Discrete. 497. 
Gaugrjenosce. 497. 
" Siliquosse. 497. 
Varioloid, 505 ; Symptoms of, 505 ; Sequelae 
of, 506 : Prognosis of, 506 ; Treatment of, 
507. 
Vascular Navel. 64. 

" Tumors, 58. 
Vemois and BecquereFs Analysis of Milk, 30. 
" ■" " •" in 

good and in average Nutrition, 37. 
Vemix Caseosa, 5. 



Vertebrae, scrofulous Inflammatio]i of the, 

564. 
Vesicle Calculi. 453 ; Symptoms of, 454; 

Course of, 455 ; Treatment of, 455. 
Vitus's Dance, St., the great, 404. 

'^ little, 395. 
Voice, Palpation of tbe, 24. 
Vomiting, 128 ; Treatment of, 130. 

■' in acute Hydrocepbalus, 345 

Vplvulus, 163. 



W. 

Warts, 516. 

Wasserkrebs, 97. 

Water-pox, 507. 

Weaning of the Child, 41. 

Wermitth, Taste of, in Milk, 38. 

Wet-nurse. Diet and Hygiene of the, 40. 
Selection of a, 30. 

Wet-nurses, Donne's Classification of. 29. 

Whip -worm. 204. 

White Swelling of the Knee-joint, 580. 

Whoopiug-cotigh, 318; Symptoms of, 318; 
"Keprise "in. 319 ; Complications of, 322; 
Diagnosis of, 323 ; Pathology of, 323 ; Eti- 
oloofV of, 324; Treatment of, 325; Lach- 
raann's Method, 329 ; Watson's, 329. 

Wintrich's Method of Exploring the Nasal 
Cavities, 245. 

Worm-disease, 201 ; Symptoms of, 205 ; Lo- 
cal, 205; general and Reflex, 206; Treat- 
ment, of, 207. 



Z. 

Zellgewebsverhartung, 67. 
Zulp, 47. 



THE END, 



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.>o 



L'BRARY OF CONGRESS 

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